i^e^'z.- 


o 


U^^ 


Columbia  Winitxttf^itp 
mtbeCitpotlltto^orfe 


^Atfnmtt  Htbrarg 


CYSTOSCOPY  AND  URETHROSCOPY 


LEWIS  and  MARK 


'l:^^^ 


f'  ), 


\  K  <> 


'-M'^'^ 


.^>  " 


Authors'  case  of  multiple  calculi  (over  1700)  and  enlarged  prostate.     See  page  9 

(Froniis  piece.) 


Cystoscopy  and  Urethroscopy 


FOR 


General  Practitioners 


BY 

BRANSFORD  LEWIS,  B.S.,  M.D.,  F.A.C.S. 

PROFESSOR   OF   GENITQ-URIXARY    SURGERY,   MEDICAL  DEPARTMENT   OF   ST.   LOUIS   UNIVERSITY, 
ST.   LOUIS,   MISSOURI,   GENITO-URINARY  SURGEON   TO   ST.    JOHN'S   HOSPITAL,  ETC. 

AND 

ERNEST  G.  MARK,  A.B.,  M.D.,  F.A.C.S. 

PROFESSOR   OF   GENITO-URINARY  AND  VENEREAL  DISEASES  IN  THE  UNIVERSITY   MEDICAL 
COLLEGE,    KANSAS   CITY,   MISSOURI,    ETC. 

WITH  A  CHAPTER 
BY 

WILLIAM  F.  BRAASCH,  M.D. 

ATTENDING   PHYSICIAN  TO   THE   MAYO  CLINIC, 
ROCHESTER,   MINNESOTA 


WITH  113  ILLUSTRATIONS,  23  OF  WHICH 
ARE  PRINTED  IN  COLORS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012  WALNUT   STREET 


Copyright,  1915,  by  P,  Blakiston's  Son  &  Co. 


THE. MAPLE. PRESS-TORK. PA 


PREFACE 

* 

Developments  in  cystoscopy  and  urethroscopy  have  been 
so  rapid  and  far-reaching  in  recent  years  that  there  has  been 
ample  room  and  need  for  the  several  excellent  text-books  on 
these  subjects  that  have  appeared  during  the  same  period. 
These  books  have  but  comported  with  the  kaleidoscopic  changes 
in  methods,  technique  and  instrumental  equipment  which  they 
have  described. 

A  similar  demand  has  impelled  the  production  of  the  present 
contribution. 

Views  on  pyelography,  on  local  anesthesia  of  the  urinary 
tract,  on  the  technical  and  other  features  of  cystoscopy  and 
urethroscopy  have  been  modernized  to  a  degree  that  demands 
the  attention  and  accurate  description  that  have  been  accorded 
them. 

While  no  large  share  of  the  book  is  devoted  to  historical 
considerations,  certain  features  and  events  are  made  clear  that 
have  been  the  subject  of  confusion  and  error  in  genito-urinary 
literature.  The  facts  related  are  based  on  historical  data  that 
are  irrefutable  and  are  confirmed  by  references  accessible  to 
anyone  interested  in  attesting  them. 

It  has  been  the  desire  of  the  authors  to  portray  the  technique 
of  cystoscopy  and  urethroscopy  so  graphically,  by  both  text 
and  illustration,  that  the  book  might  prove  of  real  value  to  the 
novice  in  furthering  his  endeavors  in  this  line,  as  well  as  of  ad- 
vantage to  the  experienced  who  may  be  interested  in  studying 
the  methods  of  others  besides  his  own.  Who  may  not  learn 
something  by  studying  the  work  of  his  confreres,  no  matter  how 
skilled  or  original  he  may  be?  In  harmony  with  this  aim,  resort 
is  had  to  photography  in  numerous  instances,  and  to  diagrams 
where  necessary.     The  steps  and  phases  of  cystoscopy,  ureteral 


vi  PREFACE 

catheterization  and  of  urethroscopy  are  depicted  from  every 
angle  conceivable;  so  that  the  student  can  hardly  escape  a  fair 
understanding  of  these,  even  if  he  does  nothing  more  than  follow 
and  study  the  illustrations. 

It  is  felt  that  the  need  of  plain  teaching  in  this  regard  is 
greater  because  of  the  relative  lack  of  opportunities  provided 
in  this  country  for  personal  instruction  and  clinical  demon- 
stration. Europe  has  been  the  Mecca  of  students  in  this 
department,  but  scientific  Europe  is  now  otherwise  engaged 
and  bids  fair  to  be  thus  diverted  for  some  time  to  come. 

It  would  seem  opportune,  therefore,  for  our  country  not 
only  to  make  its  own  cystoscopes  and  allied  appliances,  as  it 
has  been  doing  so  successfully,  but  also  to  foster  and  develop 
its  own  literature  along  these  lines. 

The  Authors. 


TABLE  OF  CONTENTS 


PART  I 
CYSTOSCOPY 

CHAPTER  I 

ANATOMY  OF  THE  BLADDER 

Pages 
Pedersen's  anatomical  divisions  of  bladder  for  purposes  of  cystoscopy.    .    .    .    1-3 

CHAPTER  II 
THE  CYSTOSCOPE.     A  HISTORICAL  REVIEW 

Bozzini,  Lichtleiter,  Segalas'  Urethro-cystic  Speculum;  Bruck's  stomato- 
scope;  Rutenberg's  air-inflation  cystoscope;  Nitze's  cystoscope;  First 
use  of  incandescent  lamp;  Boisseau  du  Rocher's  cystoscope;  Brenner's 
direct  catheterizing  cystoscope;  Albarran's  lever  device;  Low  amper- 
age lamp;  Tilden  Brown's  cystoscope;  Bransford  Lewis'  cystoscope; 
Brown-Buerger  cystoscope;  Pawlik-Kelly  cystoscope;  Cystoscopic 
Armanentarium;  Selection  of  a  cystoscope;  Cystoscopic  acces- 
sories; Care  and  sterilization  of  instruments 4-21 

CHAPTER  III 
OPERATIVE  TECHNIQUE 

Preparation  of  the  patient;  Cystoscopy  of  the  normal  bladder;  Technique 
of  air-inflation  cystoscopy;  The  Pawlik-Kelly  method;  The  appear- 
ance of  the  normal  bladder;  The  coloring  of  the  normal  bladder; 
The  vascularity  of  the  normal  bladder;  The  luster  of  the  normal 
bladder;  The  trigone;  Fallacies  in  cystoscopic  findings;  The  inter- 
pretation of  the  cystoscopic  picture 22-36 

CHAPTER  IV 
URETERAL  CATHETERIZATION 

Various  methods  for  segregation  of  the  two  urines;  Purposes  of  ureteral 
catheterization  in  diagnosis  and  treatment;  Selection  between  direct 
and  indirect  methods;  Technique  of  the  two  methods;  Selection  of 
ureteral  catheter;  Catheterization  under  forced  air-inflation;  Pawlik- 
Kelly  method;  Difficulties  encountered  in  ureteral  catheterization; 
Dangers  of  infection  and  traumatism;  Tests  for  kidney  functionation.       37-70 

vii 


Vlll  TABLE    OF    CONTENTS 

CHAPTER  V 
URETERO  -PYELO  GRAPHY 


Pages 


Technique  of;  Pathologic  conditions  of  kidney  and  ureter;  Normal  pelvis; 
Hydronephrosis;  Inflammatory  pelvic  dilatation;  Tumor  differentia- 
tion in  upper  lateral  abdomen;  The  cystic  kidney;  Localization  of 
renal  shadows;  Identification  of  intra-  and  extrarenal  shadows; 
Renal  tuberculosis;  Congenital  malformations;  Supernumerary 
ureters;  Solitary  kidney;  Ureteral  dilatation;  Contraindications  to 
uretero-pyelography 7i~93 

CHAPTER  VI 

CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

Congestion  of  bladder;  Various  forms  of  cystitis;  Stones;  Tumors;  Cystos- 
copy of.  Contraindications  to  cystoscopy  in  tumors;  Cysts;  Bilharzia 
disease;  Varices;  Tuberculosis;  Lymphoid  tubercle;  Edema  buUosum; 
Diverticulation  and  trabeculation;  Tabetic  trabeculation;  Ureteric 
meatoscopy;  Eversion  or  prolapse  of  ureteral  orifices;  Cystic  dis- 
tention of  lower  end  of  ureter 94-121 

CHAPTER  VII 
OPERATIVE  CYSTOSCOPY 

Purposes  of,  in  the  bladder  and  ureter;  Various  operative  cystoscopes; 
Nitze's  technique;  Bransford  Lewis'  instruments  and  technique; 
Cauterization;  Fulguration  of  bladder  growths;  Fulguration  appara- 
tus; Methods  of  application;  Ureteral  stricture;  Ureteral  calculus  .    122-154 

PART  II 
URETHROSCOPY 

CHAPTER  I 
ANATOMY  OF  MALE  URETHRA  155-161 

CHAPTER  II 

DEVELOPMENT  OF  THE  URETHROSCOPE 

Desormeaux'  urethroscope,  Griinf eld's  urethroscope;  Nitze-Oberlander's 
instruments;  The  exposed  platinum-loop  urethroscope;  The  low 
amperage  lamp;  Various  types  of  modern  urethroscopes;  Air-inflation 
urethroscopes;  KoUmann's  operative  urethroscope;  Mark's  operative 
urethroscope;  Water  inflation  instruments  of  Walker,  Goldschmidt, 
Buerger  and  McCarthy;  Care  and  sterilization  of  instruments.    .    .      162-169 


TABLE    OF    CONTENTS  IX 

CHAPTER  III 

URETHROSCOPY  OF  THE  NORMAL  URETHRA 

Pages 
Urethroscopy  of  the  anterior  urethra;  Technique  of;  The  points  to  be 
observed  in  the  central  figure;  The  elasticity  of  the  urethra;  The  vas- 
cularity of  the  mucosa ;  The  luster  of  the  mucosa ;  The  appearance  of 
the  lacunae  of  Morgagni  and  the  glands  of  Littre;  The  value  of  air- 
inflation  in  tirethroscopy ;  Urethroscopy  of  the  posterior  urethra; 
Urethroscopy  of  the  female  urethra 170-185 

CHAPTER  IV 

URETHROSCOPY  OF  THE  DISEASED  URETHRA 

Chronic  urethritis;  Oberlander's  classification;  The  changes  in  elasticity; 
Modifications  in  vascularity ;  Changes  in  luster ;  Appearance  of  lacunae 
of  Morgagni  and  the  glands  of  Littre;  Chronic  posterior  urethritis; 
Stricture;  Valves  and  diverticula;  Tumors  of  the  urethra;  Varices  of 
the  urethra;  Tuberculosis  of  the  urethra;  Herpes  of  the  urethra; 
Chancroid  of  the  urethra;  Syphilis  of  the  urethra;  Leukokeratosis 
of  the  urethra;  Calculi  of  the  urethra;  Cysts  of  the  prostatic  utricle; 
Argyria      186-221 

CHAPTER  V 
OPERATIVE  URETHROSCOPY 

Air-inflation  practically  indispensable;  The  treatment  of  cystic  follicles 
and  suppurating  glands;  Stricture,  methods  of  treatment  in  cases  of 
extreme  difficulty;  Papilloma,  Oberlander's  method;  Schwartz' 
method;  Author's  method;  Removal  of  other  tumors;  Removal  of 
the  verumontanum ;  Treatment  of  strictures  of  the  ejaculatory  ducts; 
Treatment  of  valves  and  diverticula  by  author's  method;  Removal 
of  foreign  bodies;  Warning  against  over  air-inflation 222-229 

Index 231 


LIST  OF  ILLUSTRATIONS 


Fig.  Page 

1.  Floor  of  bladder  and  urethra  (Pedersen) 2 

2.  Roof  of  bladder  and  urethra  (Pedersen) 2 

3.  Boisseau  du  Rocher's  cystoscope 8 

4.  Brenner's  cystoscope 9 

5.  Tilden  Brown's  modification  of  Brenner's  cystoscope 10 

6.  Bransford  Lewis'  universal  cystoscope 12 

7.  Buerger's  indirect- view  cystoscope 14 

8.  Convenient  plan  and  equipment  of  cystoscopic  room 19 

9.  Application  of  local  anesthetic 23 

10.  Introduction  of  cystoscope 24 

11.  Author's  urethral  tablet  depositor  for  male 25 

12.  Author's  urethral  tablet  depositor  for  female 26 

13.  Anterior  cystoscopic  view  showing  normal  vesical  mucosa  (Facing  page)  32 

14.  Anterior  cystoscopic  view  showing  transitional  mucosa  between  sphincter 
and  vesical  membrane (Facing  page)  32 

15.  Schematic  bottom  of  Valentine's  box  phantom 35 

16.  Valentine's  box  phantom 35 

17.  Irrigation  of  bladder  through  cystoscopic  sheath 41 

18.  Irrigation  of  bladder.     Thumb  removed,  water  escaping 42 

19.  Observ^ation  cystoscopy.     With  bladder  fuU  of  water 46 

20.  Ureteral  catheterization  (direct  method),  insertion  of  catheter  into  left 
orifice 47 

21.  Ureteral  catheterization  (direct  method),  insertion  of  catheter  into  right 
orifice 48 

22.  Showing  inaccessibility  of  ureteral  catheterization   by  direct  method  in 
the  presence  of  precipitate  bladder  or  enlarged  prostate 49 

23.  Direct  catheterization,  side  view 49 

24.  Direct  catheterization,  side  view 50 

25.  Direct  catheterization,  cystoscopic  view 51 

26.  Direct  catheterization,  catheter  inserted  into  left  ureter 52 

27.  Direct  catheterization,  both  catheters  in  place 53 

28.  Indirect  catheterization,  side  view 54 

29.  Indirect  catheterization,  catheter  inserted  into  left  ureter 54 

30.  Indirect  catheterization,  side  view,  control  of  catheter  by  lever  ....  55 

31.  Indirect  catheterization,  side  view,  showing  angulation  of  cystoscope.    .  55 

32.  Indirect  catheterization  of  left  ureter.     Approach  of  catheter 56 

33.  Indirect  catheterization,  catheter  inserted  into  left  ureter 57 

34.  Indirect  catheterization,  beak  pointing  downward 58 

35.  Withdrawal  of  lens  system  leaving  catheter  in  place 59 

36.  Cystoscope  sheath  is  being  withdrawn  with  one  hand,  while  catheters  are 
fed  in  by  the  other 61 

xi 


XII  LIST    OF    ILLUSTRATIONS 

Fig.  Page 

37.  Cystoscope  withdrawn,  catheters  draining  into  sterile  test-tubes.    ...      62 

38.  Lavage  of  left  kidney  pelvis 65 

39.  Irregtilar,  tortuous  outline  of  the  right  ureter  caused  by  blood  clot  falling 
pelvis  and  upper  ureter 72 

40.  Irregular  inflammatory  dilatation  of  the  pelvis  of  kidney  caused  by 
bleeding  pyelitis 73 

41.  Dilatation  of  right  ureter  caused  by  stone  lodged  in  that  part  of  the 
ureter  at  entrance  of  bladder 74 

42.  Beginning  of  small  hydronephrosis 76 

43.  Outline  of  normal  pelvis 78 

44.  Dilated  ureter  and  pelvis  caused  by  stone  in  lower  ureter 79 

45.  Colloidal  silver  outlining  right  ureter  rules  out  shadow  which  might  have 
been  taken  as  stone 80 

46.  Three-ureter  case  of  author 87 

47.  Post  mortem  specimen  probably  analogous  to  the  condition  shown  in 
Fig.  46 88 

48.  Radiogram  of  duplicated  ureter  and  pelvis 89 

49.  Comparison  of  sound  and  cystoscope  for  detection  of  stone 98 

50.  Multiple  stones  (over  1700)  removed  through  cystoscope .      99 

51.  Cystoscopic  view  of  tumor  of  bladder (Facing  page)   100 

52.  Cystic  granulosa  or  lymphoid  tubercle  (after  Kneise) 113 

53.  Cystic  granulosa  (after  Kneise) 113 

54.  Edema  buUosum  in  connection  with  bilateral  hypertrophied  prostate 

(Facing  page)   117 

55.  Trabeculation  and  diverticula  of  bladder  wall (Facing  page)   119 

56.  Constricted  ureteral  orifice  and  resulting  uretero- vesical  cyst  (Knorr)    .    121 

57.  Side  view  of  above,  catheter  introduced  (Knorr) 121 

58.  Bransford  Lewis'  operating  cystoscope 126 

59.  Accessories  to  Lewis'  operating  cystoscope 126 

60.  Bransford  Lewis'  air  cystoscope 129 

61.  Appurtenances  to  Lewis'  universal  operating  cystoscope 131 

62.  Combined  universal  and  operating  cystoscope  (191 4) 131 

63.  Dr.  Leo  Buerger's  ureteral  dilator 131 

64.  Bransford  Lewis'  induction  rheostat 135 

65.  Bransford  Lewis'  electric  controller 136 

66.  Bransford  Lewis'  fulguration  apparatus 139 

67.  Mode  of  fulguration  of  papilloma,  direct  method 140 

68.  Mode  of  applying  fulguration  of  papilloma,  indirect  method 141 

69.  Benign  papilloma (Facing  page)   142 

70.  Benign  papilloma  after  5  fulgurations (Facing  page)   142 

71.  Benign  papilloma  after  8  fulgurations (Facing  page)   142 

72.  Dilated  ureter  due  to  stricture 145 

73.  Stone  in  orifice  of  left  ureter 147 

74.  Removing  stone  by  alligator  forceps 148 

75.  Stone  lodged  in  mid  ureter 151 

76.  Showing  cystoscope,  X-ray  catheter  and  stone  in  lower  end  of  ureter, 
after  descent  from  position  shown  in  Fig.  75 152 

77.  Ureteral  stone  removed  from  J.  S.  F 153 

78.  Showing  strictured  right  ureteral  orifice  retaining  stone 154 


LIST    OF    ILLUSTRATIONS  XIU 

Fig.  Page 

79.  Ureteral  scissors  cutting  strictural  orifice  of  ureter 154 

80.  Orifice  widened  by  scissors 154 

81.  Ernest  G.  Mark's  aero-urethroscope 166 

82.  Patient  in  position  for  urethroscopy 171 

83.  Introduction  of  urethroscope 172 

84.  Urethroscope  introduced  and  obturator  withdrawn 173 

85.  Attaching  observation  window  preUminary  to  forced  air-inflation    ...    174 

86.  Window  attached  and  observation  carried  on 175 

87.  Introduction  of  urethroscope  into  posterior  urethra 176 

88.  Urethroscope  introduced  for  intra-urethral  operative  procedure  .    .    .    .177 

89.  Intra-urethral  operation  under  forced  air- inflation 178 

180 
180 
180 
188 
188 
188 
190 
190 
190 
190 
190 
191 
191 
191 


90.  Normal  urethra  with  vascular  mucous  membrane  ....  (Facing  page 

91.  Normal  urethra  with  anemic  mucous  membrane (Facing  page 

92.  Soft  infiltration  (acute  urethritis) (Facing  page 

93.  Glandular  urethritis (Facing  page 

94.  Same  form  as  Fig.  93  (under  treatment) (Facing  page 

95.  Same  form  as  Figs.  93  and  94  (nearly  cured) (Facing  page 

96.  Mixed  urethritis.     Hard  infiltration  second  degree ....  (Facing  page 

97.  Dry  urethritis,  infiltration  of  the  second  degree (Facing  page 

98.  Dry  urethritis,  hard  infiltration  of  the  first  degree .     .    .    .  (Facing  page 

99.  Dry  urethritis  showing  large  submucous  nodosities     .    .    .  (Facing  page 

100.  Dry  urethritis,  infiltration  second  degree (Facing  page 

loi.  Membranous  urethra,  in  normal  state (Facing  page 

102.  Normal  prostatic  urethra (Facing  page 

103.  Urethritis  of  the  prostatic  portion (Facing  page 

104.  Floor  of  the  proximal  portion  of  the  supramontanal  region 193 

105.  Normal  colliculus  with  prominent  posterior  frenula 193 

106.  Normal  colliculus  viewed  from  front 193 

107.  Atypical  colliculus  with  peculiar  utricle 193 

108.  Small  cysts  in  roof  of  the  supramontana 193 

109.  Fosstda  prostatica  and  declive 193 

no.  Inflammatory  excrescences  on  the  colliculus ,.    .    193 

111.  Small  papilloma  lying  against  colliculus 193 

112.  Enlarged  prostatic  duct  in  depressed  scar  tissue 193 


CYSTOSCOPY  AND  URETHROSCOPY 


PART  I 

CYSTOSCOPY 


CHAPTER  I 
ANATOMY  OF  THE  BLADDER 

The  bladder  is  a  hollow  muscular  organ  whose  function  it  is 
to  temporarily  hold  the  urine.  It  is  composed  of  a  serous 
peritoneal  layer  which  only  partially  covers  it,  a  muscular 
covering  which  is  made  up  of  practically  three  layers,  and  a 
mucous  lining.  Of  its  external  layers  or  its  relations  to  neigh- 
boring structures  we  are,  from  a  cystoscopic  standpoint,  con- 
cerned but  little.  Aberrations  in  such  neighboring  structures 
may  involve  changes  in  the  contour  of  the  bladder  as  observed 
through  the  cystoscope  but  it  is  unnecessary  to  enter  into  a 
detailed  discussion  of  such  changes. 

The  mucous  coat  is  covered  with  a  stratified  pavement 
epithelium  and  richly  supplied  with  blood  vessels.  The  blood 
supply  is  finer  and  more  closely  woven  on  the  trigonal  area, 
or  that  area  which  is  formed  by  the  interuretic  fold,  or  ridge,  as 
a  base  and  the  internal  vesical  meatus  as  an  apex.  Viewed 
through  the  cystoscope  the  mucosa  has  a  characteristic  luster 
and  the  branching  vessels  give  it  a  marked  retinal  appearance, 
except  on  the  trigone.  Here  the  fine  interweaving  of  the  vessels 
gives  to  this  area  a  reddened  or  a  reddish-pink  appearance  as 
contrasted  with  the  delicate  straw  color  of  the  mucosa  in  other 
parts  of  the  bladder.  Forming  the  base  of  the  trigone  is  the 
interuretic  fold  or  ridge  at  the  ends  of  which  are  situated  the 
orifices  of  the  ureters.  Normally,  these  openings  appear  as 
slits  or  dimples,  marked  by  some  increase  in  vascularity. 


CYSTOSCOPY   AND    URETHROSCOPY 


The  sides  of  the  trigone  are  about  one  and  a  quarter  inches 
long,  though  this  is  variable  within  normal  limits.  Any  one  of  the 
sides  of  the  trigone  may  be  lengthened  or  shortened,  the  variation 
depending  upon  the  point  at  which  the  ureter  enters  the  bladder. 


Figs,  i  and  2. 


rLUUK  ROOF 

Fig.  I.  Fig.  2. 

•Anatomical  divdsions  of  bladder  for  purposes  of  cystoscopy. 
Pedersen.) 


(After 


In  a  condition  of  distention,  the  bladder  assumes  a  globe-like 
shape.     In  collapsing  the  mucosa  falls  in  numerous  folds. 

For  the  purposes  of  the  cystoscopist  the  bladder  has  been 
divided  by  Dr.  V.  C.  Pedersen,*  into  four  segments  or  quadrants. 

*  Topography  of  the  Bladder  with  Especial  Reference  to  Cystoscopy,  V.  C.  Pedersen, 
N.  Y.  Med.  Jour.,  Aug.  23,  1913. 


ANATOMY   OF    THE   BLADDER 


Our  division  is  obtained  by  an  imaginary  plane  being  passed 
transversely  through  the  bladder  just  posterior  to  the  point  at 
which  the  ureteric  folds  disappear  into  the  bladder  wall.  This 
divides  the  bladder  into  superior  and  inferior  halves.  Another 
imaginary  plane  passed  vertically  through  the  bladder  and 
urethra  divides  the  bladder  into  anterior  and  posterior  halves. 
The  bladder  is  thus  divided  into  four  quadrants  or  segments, 
which  form  excellent  divisions  for  cystoscopic  classification  and 
study  (see  Figs,  i  and  2). 

Pedersen  has  denoted  these  divisions  as  follows : 

"First,  the  posterior  lower  quadrant,  or,  better,  the  uretero- 
trigonal  quadrant,  containing  the  right  ureter  and  its  fold,  the 
interureteric  fold,  the  left  ureter  and  its  fold,  trigonum,  and  the 
posterior  half  of  the  neck. 

"Second,  the  posterior  upper  quadrant,  or  by  choice  the  sub- 
peritoneal quadrant,  which  lies  beyond  the  ureteric  and  inter- 
ureteric folds,  and  is  not  infrequently  called  the  deep  base  or 
deep  fundus  of  the  bladder. 

"Third,  the  anterior  upper  quadrant,  or  preferably  the 
urachal  quadrant,  inasmuch  as  this  contains  the  true  apex  of  the 
bladder  with  the  remnants  of  the  implantation  of  the  fetal  struct- 
ure, the  urachus.  This  quadrant  might  also  be  well  known  as  the 
apical  zone. 

"Fourth,  the  anterior  lower  quadrant,  which  might  suitably 
be  noted  as  the  retropubic,  inasmuch  as  it  lies  immediately 
behind  the  symphysis  pubis  and  contains  the  anterior  half  of  the 
neck  of  the  bladder. 

"  The  importance  of  the  neck  of  the  bladder,  and  the  fact  that 
it  is  best  explored  with  the  retrovision  telescope,  or  with  the 
urethroscope,  might  be  regarded  by  many  as  reasons  for  making 
it  a  fifth  subdivision  for  ofhce  records  and  the  like." 

For  the  purposes  of  cystoscopic  study  and  topographical 
classification  these  divisions  of  the  bladder  are  excellent  and  are 
to  be  recommended. 


CHAPTER  II 
THE  CYSTOSCOPE.     A  HISTORICAL  REVIEW 

The  history  of  cystoscopy  and  endoscopy  in  general  dates 
from  the  pioneer  work  of  Bozzini  of  Frankfort.  Bozzini's 
instrument,  which  he  termed  a  "Lichtleiter,"  was  first  described 
by  him  in  the  Journal  der  praktischen  Heilkunde,  Bd  XXIV, 
1806.  The  vesical  speculum,  which  was  a  part  of  Bozzini's 
instrument,  was  intended  only  for  the  female  bladder  as  observa- 
tion of  the  male  bladder  was  considered  out  of  the  question. 
This  speculum  resembled  a  funnel.  The  spout  of  this  funnel  was 
one  and  a  half  inches  long  and  about  one-sixth  inch  in  diameter. 
A  metallic  elastic  spiral  near  the  distal  extremity  of  the  tube 
permitted  some  degree  of  mobility  of  the  bladder  end  of  the  tube. 
A  shaded  stand  contained  the  source  of  light — a  candle.  The 
report  of  the  Medical  Faculty  of  Vienna  and  the  Josephine 
Academy  that  were  appointed  by  the  Austrian  government  to 
investigate  the  claims  of  Bozzini  in  behalf  of  his  instrument 
was  distinctly  unfavorable  both  as  to  the  invention  as  it  stood 
and  the  possibility  of  its  future  development. 

This  pessimistic  view  discouraged  further  advance  in  cyst- 
oscopy until  December,  1826,  at  which  time  Segalas  of  Strasburg 
presented  his  " Urethro-cystic  Speculum"  before  the  Royal 
Academy  of  Sciences  of  France.  The  shape  of  Segalas'  speculum 
was  similar  to  that  of  Bozzini's.  The  endoscopic  tube  was 
separable  from  the  funnel  which  was  in  reality  a  conical  mirror. 
A  second  mirror,  concave  in  shape,  through  the  center  of  which 
was  a  hole  for  the  introduction  of  an  ocular  tube,  was  used 
as  a  reflector  for  the  two  candles  that  formed  the  source  of 
illumination.  The  instrument  had  little  of  practical  value  to 
recommend  it. 

4 


THE    CYSTOSCOPE 


The  following  year,  1827,  John  Fisher  of  Boston  described 
in  the  Philadelphia  Journal  of  the  Medical  and  Physical  Sciences 
quite  a  complicated  instrument  for  the  purposes  of  endoscopy. 
It  consisted  of  three  tubes  and  two  mirrors,  one  of  them  concave 
for  the  purpose  of  reflecting  the  light  of  the  candle.  It  will  be 
readily  understood  that  this  instrument  found  no  adherents. 

From  this  time  up  to  the  year  1853,  very  little  was  accom- 
plished. Avery,  Cazenave,  Gessler,  Malherbe  and  Espezel  were 
endeavoring  to  forward  the  progress  of  endoscopy  but  their 
efforts  were  without  definite  results.  In  1853,  Desormeaux,  to 
whom  has  been  given  the  title,  "the  father  of  endoscopy,'^ 
following  the  ideas  of  Fisher,  produced  his  endoscope  and  two 
years  later  this  instrument  was  presented  before  the  Imperial 
Academy  of  Medicine  in  Paris.  The  instrument  of  Desormeaux 
was  in  reality  the  first  to  receive  practical  acceptance  at  the 
hands  of  the  medical  profession,  and  in  recognition  of  his  labors 
Desormeaux  was  awarded  a  portion  of  the  Argenteuil  Prize. 
In  Germany,  Furstenheim,  and  in  America,  Robert  Newman, 
did  much  to  popularize  endoscopy  as  proposed  by  Desormeaux. 
In  1865,  Cruise  of  Dublin  developed  the  efficacy  of  Desormeaux's 
instrument  to  a  marked  degree  by  improving  the  reflecting 
apparatus  and  the  vesical  specula. 

In  1862,  August  Haken  of  Riga  proposed  in  the  Wiener 
medizinische  Wochenschrift,  March  22,  1862,  the  use  of  metallic 
tubes  blackened  on  the  inside  and  into  which  the  light  was 
reflected  by  means  of  a  head  mirror. 

Dating  from  the  work  of  Desormeaux,  endoscopy  steadily 
advanced  and  with  the  invention  of  the  Stomatoscope  by  Dr. 
Julius  Bruck  of  Breslau  in  1867  a  new  era  was  inaugurated — 
the  platinum  loop  period.  It  seems  rather  remarkable  that 
the  difficulties  presented  in  the  exposed  platinum  loop  were  not 
overcome  for  a  period  of  ten  years  following  its  introduction. 

In  1874,  Grlinfeld,  acting  on  the  principles  suggested  by 
Haken,  presented  his  vesical  specula.  These  tubes  were  closed 
at  their  vesical  extremity  by  glass  windows  which  allowed  the 


6  CYSTOSCOPY   AND    URETHROSCOPY 

bladder  to  be  distended  with  water.  By  means  of  the  view  so 
secured  he  was  enabled  to  locate  the  ureteral  orifice  and  suc- 
ceeded in  inserting  a  small  bougie  passed  alongside  the  tube 
into  the  ureter. 

Two  years  later,  1876,  Rutenberg  of  Vienna  (Deutsche 
Zeitschrift  fiir  prakt.  Medizin,  Feb.  12,  1876)  presented  his 
cumbersome  female  vesical  speculum  to  the  profession.  It 
deserves  mention  only  by  reason  of  the  fact  that  in  its  use 
Rutenberg  employed  forced  inflation  of  the  bladder  with  air,  a 
principle  which  remained  neglected  for  a  number  of  years  before 
it  was  finally  accorded  a  permanent  place  in  cystoscopy. 

In  1877,  Dr.  Max  Nitze  of  Berlin,  utilizing  Bruck's  idea  of 
the  incandescent  platinum  loop  devised  the  first  electric  cysto- 
scope.  This  instrument  embodied  the  three  principal  factors  of 
modern  cystoscopy — the  electric  source  of  illumination,  the 
placing  of  the  source  of  light  in  the  instrument  near  the  field  to 
be  examined  and  the  use  of  a  lens  system.  The  efforts  of  all 
previous  laborers  in  the  field  of  endoscopy  pale  into  insignifi- 
cance when  compared  with  the  signal  achievement  of  Nitze. 

The  first  lens  system  of  Nitze  was  made  for  him  by  Beneche, 
an  optician  of  Vienna,  and  was  composed  of  a  series  of  telescopic 
lenses.  This  telescopic  lens  system  was  pushed  down  till  its 
distal  extremity  presented  at  a  window  placed  at  the  convexity 
of  the  angle  of  the  shaft  with  the  beak  of  the  instrument.  The 
view  obtained  was  direct  and  was  limited  to  the  posterior  wall 
and  base  of  the  bladder.  The  instrument  as  a  whole  was  the 
work  of  Diecke,  a  Dresden  instrument  maker,  and  many  of  the 
valuable  suggestions  toward  its  building  emanated  from  Ober- 
lander  who  was  one  of  its  earliest  exponents. 

Later,  Nitze  placed  the  manufacture  of  the  cystoscope  in  the 
hands  of  Leiter  of  Vienna  and  the  masterly  mechanical  skill 
displayed  by  the  latter  evolved  the  Nitze-Leiter  cystoscope  as  it 
was  presented  before  the  Medical  Society  of  Vienna  on  March 
9,  1879. 

The  instrument  was  presented  in  two  forms — one  similar  to 


THE    CYSTOSCOPE  7 

the  Nitze  cystoscope  of  1877,  and  one  in  which  by  means  of  the 
intervention  of  a  prism  in  the  lens  system,  a  view  was  obtained 
of  the  neck,  anterior  wall  and  sides  of  the  bladder.  The  window 
in  the  latter  form  was  placed  on  the  shaft  of  the  instrument  at 
the  concavity  of  the  angle  formed  between  the  beak  and  shaft. 
The  aperture  for  the  exit  of  the  light-rays  in  the  back  was  closed 
by  a  piece  of  rock-crystal. 

On  account  of  the  great  heat  generated  by  the  platinum  loop, 
an  arrangement  for  the  purpose  of  keeping  a  stream  of  cold 
water  circulating  in  the  instrument  was  essential.  This  was 
accomplished  by  means  of  two  channels  in  the  shaft  which  united 
in  the  beak.  During  cystoscopy  a  constant  flow  of  cold  water 
was  maintained. 

The  complicated  character  of  the  instrument  required  the 
services  of  a  competent  electrician  for  its  management  and, 
even  in  the  most  skilled  hands,  the  platinum  wire  became  fused 
so  frequently  as  to  place  the  instrument  beyond  the  pale  of 
practicability.  But  with  all  of  its  drawbacks  its  use  was  urged 
by  practically  all  of  the  leading  workers  in  the  field  of  gen- 
itourinary surgery.  Roswell  Park  of  Buffalo  was  among  the 
first  to  advocate  its  use  in  this  country. 

The  application  of  the  Edison  incandescent  lamp,  devised 
in  1880,  to  other  forms  of  endoscopy  was  advocated  for  some 
time  previous  to  its  introduction  into  cystoscopy.  On  January 
18,  1883,  David  Newman  of  Glasgow  used  the  first  incandes- 
cent-lamp cystoscope  and  yet  it  was  not  until  March,  1887 — over 
four  years  later — that  this  form  of  cystoscopic  illumination 
was  presented  to  the  general  profession.  At  this  time  two  in- 
candescent-lamp cystoscopes  appeared — one  made  by  Hartwig 
of  Berlin  after  the  suggestions  of  Nitze  (Illustrirte  Monatsschrift 
der  arztlichen  PolytechnLk,  March,  1887),  and  the  other  by 
Leiter  of  Vienna  (Konig.  Gesellschaft  der  Aerzte  zu  Wien, 
March,  1887).  By  means  of  the  use  of  the  incandescent  lamp, 
three  distinct  factors  of  advantage  were  obtained:  The  dis- 
carding of  the  cumbersome  cooling  device,  the  enlargement  of 


8  CYSTOSCOPY   AND   URETHROSCOPY 

the  lens  system  with  a  consequent  enlargement  of  the  cystoscopic 
field,  and  the  far  greater  reliability  of  the  source  of  light. 
With  these  advantages  there  ensued  much  greater  interest  in 
cystoscopy  and  its  far  wider  acceptance  in  the  field  of  urology. 
In  the  same  year  (1887)  Dittel  (ref.  Casper's  Handbuch  der 
Cystoscopie,  1898,  pp.  16-17)  modified  Nitze's  model  by  placing 
the  illumination  lamp  on  the  tip  of  the  beak  instead  of  within 
the  beak. 

In  1885  Boisseau  du  Rocher  of  Paris  showed  the  first  model 
of    his    indirect- view,    incandescent-lamp    "  megaloscope, "    or 


A 

SKeaXvT 


TeUbCope  (mega\oscop?) 


Fig.  3. 


cystoscope,  by  which  he  claimed  to  give  a  larger  field  of  vision 
through  his  lens  system.  In  1889  he  had  further  developed  and 
changed  the  instrument  so  that,  as  described*  by  him  in 
that  and  succeeding  years,  it  represented  the  first  completed 
model  of  composite  cystoscope  (Fig.  3)  presenting  the  first 
cystoscope  built  on  the  separable  sheath-and- telescope  plan; 
the  first  and  original  attainment  of  double,  synchronous  catheteri- 
zation of  the  ureters  (by  two  independent  ureteral  catheters  at 
the  same  sitting);  the  first  to  afford  free  irrigation  facilities 
through  the  cystoscope  itself.     The  two  models  of  the  instru- 

*  Du  Rocher,  Annales  des  Mai.  des  Org.  Gen.-Urin.,  1890,  pp.  65-93. 


THE    CYSTOSCOPE  9 

merit  of  that  year  (1889)  furnished  both  the  direct  and  the  in- 
direct view  of  the  interior  of  the  bladder;  and  the  successful  use 
of  the  catheterizing  features  was  reported  by  Poirier,  a  surgeon 
of  Paris.*  Nine  years  later  (1898),  Boisseau  du  Rocherf 
had  combined  the  several  original  features  of  his  instru- 
ment into  one  combination  cystoscope  the  first  composite 
sheath-and- telescope  instrument  of  the  kind  ever  devised, 
the  features  of  which  have  since  been  utilized  in  the  produc- 
tion of  a  number  of  the  composite  cystoscopes  now  on  the 
market. 

In  1889,  Brenner  modified  Leiter's  direct  view  cystoscope 
for  the  purpose  of  irrigation  during  cystoscopy.  The  modifica- 
tion consisted  of  the  addition  of  a  small  tube  on  the  shaft  of  the 
instrument,  as  is  shown  in  Fig.  4.     It  was  but  a  step  from  the 


y^ 


yf 
^ 


Breooer 

Fig.  4. 


utilization  of  the  tube  for  purposes  of  irrigation  to  its  adaptation 
as  a  catheter  channel;  the  same  year  (1889)  thereby  furnishing 
another  ureter-catheterizing  cystoscope  to  the  profession.  By 
its  means,  Zuckerkandl  and  others  were  enabled  to  catheterize 
successfully  the  ureter  in  the  male.  James  Brown  of  Baltimore 
is  credited  with  being  the  first  in  America  to  accomplish  ureteral 
catheterization  in  the  male,  making  use  of  this  instrument. 

Following  the  application  by  Brenner  and  du  Rocher  of  the 
catheterizing  principle  to  the  cystoscope,  Casper  (1894),  Nitze 
(1894),  and  Albarran  (1897)  caused  the  construction  of  cysto- 
scopes having  a  similar  end  in  view.  To  Albarran  must  be 
given  the  credit  of  originating  the  lever-device,   adopted  in  so 

*  Poirier,  An.  d.  Mai.  des  Org.  G.-Urin.,  1889,  p.  625. 

t  Du  Rocher,  An.  d.  Mai.  des  Org.  G.-Urin.,  1898,  p.  485. 


lO 


CYSTOSCOPY   AND   URETHROSCOPY 


many  subsequent  instruments,  for  controlling  the  angle  or 
direction  of  the  ureteral  catheter  as  it  leaves  the  cystoscope 
to  go  to  the  ureteral  orifice,  in  the  indirectcatheterizing  instru- 
ments. 

In  1898  Charles  Preston  of  Rochester,  New  York,  invented 
his  ''cold"  lamp,  used  first  in  the  Valentine  urethroscope,  and 
later  in  the  Koch  air-cystoscope.  In  connection  with  the  latter 
there  were  sheath  and  telescopes  affording  both  direct  and 
indirect  vision;  and  a  separate  tube  for  carrying  a  ureteral 
catheter.     In    the    same    year    (1898)    Casper   provided    for 


flight  angle  vie*/ 
C 


direct 

Cattieterizing 


Fig.  5. 


double  synchronous  ureteral  catheterization  by  having  a  sliding, 
removable  cover  for  the  catheter  groove.  In  1899  F.  Tilden 
Brown*  modified  the  Brenner  instrument  by  adding  two  ure- 
teral catheter  tubes  instead  of  the  one  it  possessed,  emu- 
lating the  plan  of  Boisseau  of  ten  years  before,  and  retaining 
the  direct  view  only.  In  1900  Bransford  Lewisf  presented  his 
first  model  of  cystoscope  (Fig.  60)  for  both  male  and  female; 
fixed  ureter  catheter  channel,  at  first  single,  shortly  afterward 


*  F.  Tilden  Brown,  Annals  of  Surgery,  1899,  p.  668. 

t  Bransford  Lewis,  Jl.  of  Cutan.  and  G.-U.  Dis.,  Sept.,  1900. 


THE    CYSTOSCOPE  II 

double;  to  be  used  with  air  as  a  distending  medium.  In  1901 
Tilden  Brown*  presented  his  first  model  of  composite  cysto- 
scope  (Fig.  5),  with  sheath,  direct  and  indirect- view  tele- 
scopes, and  double  ureter  catheter  channels  by  the  direct 
method  only;  setting  the  lamp  at  the  tip  of  the  beak,  after  the 
plan  of  Dittel  of  1887. 

In  1902  Bierhoff  submitted  a  modification  of  the  Nitze 
catheterizing  instrument  that  was  of  materia]  advantage, 
making  the  sheath  and  telescope  separable,  for  permitting  the 
removal  of  the  cystoscope  from  the  bladder  while  the  two 
catheters  were  left  in  the  ureters — something  impracticable  with 
the  indirect  catheterizing  instruments  then  existing. 

In  1903  Schlagintweitf  introduced  a  new  idea  into  cys- 
toscopy by  affording  a  retrospective  view  (of  the  neck  of  the 
bladder  and  the  prostate)  by  means  of  a  movable  lens.  This 
instrument  was  non-catheterizing. 

In  1904  Bransford  LewisJ  reported  the  use  of  his  operative 
cystoscope  (Fig.  58),  adapted  not  only  to  use  within  the  bladder 
but  also  in  the  ureters.  The  direct-vision  air  cystoscopes  of 
Luys,§  and  of  CathelinU  were  submitted  in  1904  and  1905, 
and  attracted  considerable  attention  in  France. 

In  i9o6#  the  first  model  of  the  Universal  cystoscope  of 
Bransford  Lewis  was  presented — at  first  (March  22)  before  the 
Chicago  Urological  Society,  and  later  before  the  American 
Urological  Association  (June  4).  Its  distinctive  features  were: 
the  fenestration  of  the  beak  on  both  concavity  dna  convexity, 
with  the  setting  of  the  cold  lamp  upside  down  in  the  beak, 
throwing  the  light  to  best  advantage  where  desired;  free  irriga- 
tion provided  for,  both  for  cleansing  the  bladder  and  for  the 
exchange  of  fluids  during  the  cystoscopic  work,  even  while  any 

*  F.  Tilden  Brown,  Med.  and  Surg.  Reports  of  Bellevue  Hosp.,  Jan.,  1905. 
t  Schlagintweit,  Ctralbl.  f.  d.  Krkhtn.  d.  Harn.-u.  Sex.  Org.,  1900,  p.  130. 
t  Lewis,  Trans,  of  Miss.  Valley  Med.  Assn.,  Oct.  11,  1904. 

§  Luys,  Trans,  de  I'Assn.  Francaise  d'Urol.,  1904,  p.  522. 

II  Cathelin,  Trans,  de  la  Soc.  de  Chir.  de  Paris,  May  24,  1905. 

#  Lewis,  American  Jour,  of  Urology,  December,  1906. 


12 


CYSTOSCOPY   AND    URETHROSCOPY 


Fig.  6. — Bransford  Lewis's  Univer 
sal  Cystoscope  (1906). 


THE    CYSTOSCOPE 


13 


of  the  several  telescopes  were  in  place  or  during  efforts  at  catheteri- 
zation; the  application  of  three  different  observation  telescopes, 


direct,  right-angle,  and  retrospective,  for  the  one  sheath.     At 
this  time  the  direct  method  of  catheterization  (double,  synchro- 


14  CYSTOSCOPY   AND    URETHROSCOPY 

nous)  was  the  only  one  provided  for,  but  plans  were  soon  com- 
pleted (1907)  for  another  telescope  affording  double  ureter 
catheterization  by  the  indirect  method,  so  that,  from  the  stand- 
point of  mechanics,  the  two  methods  of  ureteral  catheterization, 
the  direct  and  the  indirect,  were  executed  with  the  same  degree 
of  precision  and  satisfaction;  and  further,  as  provided  for  by  the 
present  universal  instrument  (Fig.  6),  both  telescope  and 
sheath  are  removable  with  equal  ease,  while  leaving  the  two 
catheters  within  the  ureters. 

In  1907  F.  Tilden  Brown  (Transactions  of  the  American 
Association  of  Genito- Urinary  Surgeons,  1907,  p.  371) 
presented  his  new  model  of  composite  cystoscope,  in  which  the 
lamp  was  removed  from  the  tip  to  the  interior  of  the  beak,  set 
upside  down;  and  three  observation  and  two  catheterizing 
telescopes  were  provided,  as  in  the  Lewis  model  of  1906. 

The  Brown-Buerger  cystoscope  (Fig.  7)  was  introduced  by 
Dr.  Buerger  in  1909.  It  possesses  the  following  features:  A 
short  beak,  set  at  a  very  obtuse  angle  with  the  shaft,  adding 
to  the  ease  of  introduction  and  manipulation;  two  removable 
telescopes,  one  for  observation  and  the  other  for  double  ureteral 
catheterization,  by  the  indirect  method  only.  For  those  who 
prefer  to  work  by  indirect  vision  only  this  is  a  very  convenient 
and  serviceable  instrument. 

Our  universal  cystoscope  was  made,  from  1906  to  1907, 
by  the  Wappler  Company,  of  New  York;  from  1907  to  19 14 
by  the  Kny-Scheerer  Co.  of  New  York.  The  newest  model, 
combining  the  examining,  catheterizing  and  operating 
features  (Figs.  61  and  62),  is  being  made  by  the  Wappler 
Company.  * 

Many  other  ingenious  modifications  of  the  modern  cysto- 
scope have  been  made  by  various  workers  in  the  field  of  cysto- 

*  The  historical  incidents  and  chronological  data  of  the  developments  in  modern 
cystoscopes  are  given  in  extenso  in  the  following  papers  by  the  author:  "Resum6  of 
Progress  in  the  Development  of  Modern  Cystoscopes,"  Transactions  of  American 
Urological  Assn.,  1908;  "Originality  and  Priority  in  Modern  Cystoscopes,"  Buffalo 
Medical  Journal,  August,  1908. 


THE    CYSTOSCOPE  1 5 

scopy  among  whom  may  be  mentioned  Follen  Cabot,  Winiield 
Ayres  and  Buerger  in  this  country;  Newman  of  Glasgow;  Casper 
in  Germany,  and  Albarran  in  France.  The  apparatus  of 
Newman  for  determining  the  accurate  location  of  lesions  seen 
through  the  cystoscope  deserves  especial  mention,  as  does 
his  binocular  attachment  which  makes  it  possible  for  both 
demonstrator  and  student  to  observe  the  cystoscopic  field  at  the 
same  time. 

The  labors  of  Kelly  of  Baltimore  in  popularizing  the  method 
of  himself  and  Pawlik  in  cystoscopy  in  the  female  are  deserv- 
ing of  great  credit.  By  his  advocacy  of  the  method  and  his 
untiring  energy  in  this  field,  Kelly  did  much  toward  awaken- 
ing interest  in  cystoscopy  and  catheterization  of  the  ureters 
in  the  female.  His  cystoscopic  tubes  are  of  service  in  some  of 
the  cystoscopic  maneuvers  in  the  female  bladder  but  for  cysto- 
scopy per  se  or  for  ureteral  catheterization  they  are  not  to  be 
compared  to   the  modern  types  of  cystoscopes. 

Consideration  of  the  various  instruments  designed  for  in- 
travesical operative  procedures  will  be  taken  up  later  when 
dealing  with  operative  cystoscopy. 

The  Cystoscopic  Armamentarium. — The  cystoscopic  arma- 
mentarium is  dependent  upon  the  amount  of  work  to  be  done. 
If  serious  and  systematic  cystoscopy  is  to  be  attempted,  instru- 
ments answering  several  requirements  are  essential.  These 
essentials  may  be  summed  up  as  follows:  (i)  A  direct  view  of  the 
base  and  posterior  wall  of  the  bladder;  (2)  a  right- angle  view  of 
the  sides,  apex  and  trigonal  area;  (3)  a  retrospective  view  of  the 
area  surrounding  the  internal  urethral  orifice;  (4)  simultaneous 
catheterization  of  both  ureters  by  the  direct  method;  (5)  simul- 
taneous catheterization  of  both  ureters  by  the  indirect  method; 
(6)  free  irrigation  of  the  bladder  through  the  cystoscope  during 
the  cystoscopic  examination. 

It  is  unnecessary  to  possess  both  long  and  short  shafted 
cystoscopes  for  use  in  either  the  male  or  female.  In  fact  the 
long  shafted  instruments  are  to  be  preferred  on  account  of  the 


l6  CYSTOSCOPY   AND    URETHROSCOPY 

distance  placed  between  the  face  of  the  cystoscopist  and  the 
genital  organs  of  the  patient. 

Realizing  the  importance  of  these  essential  points  and  the 
discomfort  to  the  patient  and  the  delay  occasioned  by  the  with- 
drawal and  introduction  of  separate  cystoscopes  during  the 
cystoscopic  seance,  the  Bransford  Lewis  Universal  Cystoscope 
was  devised.  With  the  one  sheath  it  fulfills  all  of  these  require- 
ments. The  different  cystoscopes  of  Bierhoff,  Casper,  Nitze 
and  Albarran  each  combine  some  of  these  essential  requirements 
but  in  none  of  them  are  all  of  the  essentials  present. 

The  necessity  for  the  possession  of  direct,  right  angle  and 
retrospective  view  instruments  is  readily  understood  and  re- 
quires no  explanation.  When  possible,  catheterization  of  the 
ureters  by  the  direct  method  is  preferable  to  the  use  of  the 
indirect  but  there  are  numerous  cases  in  which  it  is  impossible 
or  impracticable  to  utilize  the  former,  thus  making  it  necessary 
to  possess  both  types  of  instrument. 

In  pronounced  hematurias  and  pyurias,  the  fluid  used  as  a 
distension  medium  may  cloud  up  so  quickly  as  to  make  success- 
ful cystoscopy  impossible  in  the  absence  of  free  irrigation 
through  the  cystoscope  during  cystoscopy.  With  an  instrument 
in  which  such  free  irrigation  is  practicable,  this  source  of  failure 
is  eliminated.  While  formerly  we  were  of  the  opinion — basing 
this  opinion  on  the  use  of  the  so-called  irrigating  cystoscopes  then 
extant — that  in  cases  of  active  hemorrhage  from  the  bladder, 
kidneys,  or  posterior  urethra,  successful  cystoscopy  was  im- 
possible with  the  use  of  a  fluid  distending  medium,  we  have  since 
modified  these  views  and  with  the  exception  of  its  occasional  use 
in  operative  cystoscopy,  consider  that  air-inflation  is  to  be  re- 
legated to  the  past. 

The  Choice  of  Cystoscopes. — While  the  selection  of  the 
necessary  cystoscopes  is,  in  a  degree,  dependent  upon  the 
individual  preference  of  the  cystoscopist,  still  such  instruments 
must  fulfill  certain  requirements. 

(i)   They  must  be  of  perfect  workmanship,  must  not  be 


THE    CYSTOSCOPE  1 7 

complicated  or  cumbersome,  and  their  individual  parts  must 
be  readily  replaceable  in  case  of  accident.  This  latter  require- 
ment applies  especially  to  the  cystoscopic  lamp.  The  lamp 
must  be  capable  of  a  maximum  of  light  with  a  minimum  of  heat 
production. 

(2)  They  must  permit  of  facility  in  cleansing.  Ease  in 
cleansing  is  readily  possible  in  instruments  of  the  "sheath" 
type.  Catheter  channels  which  cannot  be  thoroughly  cleansed 
are  an  obvious  source  of  danger. 

(3)  The  lens  system  must  give  for  its  caliber  the  largest 
possible  cystoscopic  field  with  the  least  loss  of  light.  In  this 
respect,  the  American,  or  hemispherical,  lens  system  has  not 
been  equaled. 

(4)  The  caliber  of  the  shaft  must  be  the  smallest  compatible 
with  the  requirements  of  the  instrument.  The  shaft  must  be 
sufficiently  long  for  cystoscopy  in  the  presence  of  an  elongated 
prostatic  urethra  due  to  hypertrophy. 

(5)  The  beak  must  be  long  enough  to  facilitate  its  intro- 
duction with  a  minimum  of  discomfort  and  yet  not  so  long  as  to 
interfere  with  easy  intravesical  manipulation.  The  angle  of 
the  beak  with  the  shaft  should  be  about  135°. 

(6)  It  must  permit  of  free  irrigation  during  cystoscopy. 

(7)  It  must  permit  of  an  indirect  view,  a  retrospective  view 
and  a  direct  view  through  the  same  sheath.  This  necessitates 
the  fenestration  of  the  beak  on  both  the  concavity  and  the 
convexity. 

(8)  It  must  permit  of  double  synchronous  catheterization 
of  the  ureters  by  both  the  Brenner  and  Nitze  methods.  It 
should  permit  of  the  use  of  not  less  than  a  No.  6  French  catheter. 

Cystoscopic  Accessories. — The  electric  current  used  may  be 
that  from  a  dry  or  wet  cell  battery  or  the  dynamo-generated 
current  controlled  by  a  suitable  rheostat.  For  office  and  hos- 
pital work  the  latter  form  of  current  is  preferable  on  account  of 
the  instability  of  the  battery.  In  the  use  of  the  dynamo-gen- 
erated current,  one  source  of  great  annoyance  may  be  frequently 


10  CYSTOSCOPY   AND    URETHROSCOPY 

encountered,  especially  if  the  floor  of  the  room  used  for  cysto- 
scopy be  of  tile,  stone  or  concrete.  The  current  may  become 
grounded  through  the  patient  or  operator  and  while  this  ground- 
ing is  not  necessarily  accompanied  by  danger,  it  is  a  source 
of  great  discomfort  and  is  a  factor  opposed  to  successful  cystos- 
copy. This  grounding  may  be  avoided  in  various  ways,  the 
most  simple  of  which  is  the  intervention  between  the  operating 
table  and  the  floor  of  a  rubber  mat,  sufflcently  large  for  the 
operator  to  stand  upon.  The  use  of  rubber  gloves  and  a  rubber- 
castered  table  provides  fair  non-conduction.  Where  a  special 
room  for  cystoscopy  is  to  be  constructed,  the  tile  floor  may  be 
insulated  against  grounding  by  means  of  an  asphalt  base, 
surrounded  with  rubber  (see  also  p.  135  relating  to  Rheo- 
stats') . 

For  the  injection  of  the  bladder  with  the  fluid  used  for  dis- 
tension, a  syringe  of  known  capacity  should  be  employed.  We 
have  for  some  time  past  been  using  a  Politzer  bag  for  irrigation 
and  distension  and  have  found  it  thoroughly  practicable  and 
satisfactory.  The  Janet  syringe  having  a  capacity  of  one- 
hundred  and  fifty  cubic  centimeters  is  a  most  excellent  instru- 
ment.    It  is  readily   sterilizable. 

In  making  cystoscopic  examinations,  the  use  of  a  table  espe- 
cially adapted  to  the  purpose  is  a  source  of  much  comfort  and 
satisfaction  to  both  patient  and  operator. 

The  catheters  used  in  ureteral  catheterization  should  be  of 
the  finest  quality  of  woven  silk.  They  should  be  of  varying  sizes 
and  coloring.  The  zebra  catheters,  graduated  into  centimeters, 
alternately  black  and  yellow  or  red  are  an  invaluable  addition  to 
the  armamentarium  of  the  cystoscopist.  The  subject  of  ureteral 
catheters  will  be  more  fully  considered  in  discussing  catheteriza- 
tion of  the  ureters. 

Care  and  Sterilization  of  Instruments. — The  care  and  sterili- 
zation of  cystoscopes  and  ureteral  catheters  are  points  of  con- 
siderable importance.  The  cystoscope  is  essentially  an  instru- 
ment of  delicate  construction  and  on  account  of  this  delicacy 


THE    CYSTOSCOPE 


19 


20  CYSTOSCOPY   AND    URETHROSCOPY 

and  its  high  cost  it  requires  especial  attention.  Fortunately,  in 
its  development,  while  it  has  lost  nothing  of  intricacy,  improved 
methods  of  modern  manufacture  have  eliminated  the  earlier 
defects  of  its  construction  so  that  it  has  become  a  stable  and 
dependable  instrument  not  requiring  the  constant  services  of  a 
skilled  electrician.  While  formerly  the  European  instruments, 
in  case  of  accident  to  any  essential  part  of  their  mechanism,  had 
to  be  returned  to  their  makers  for  repair,  they  are  now  so  con- 
structed that  their  parts  are  readily  replaceable.  It  is  to  the 
credit  of  American  manufacturers  that  this  feature  of  stability 
and  ready  repair  has  always  been  kept  in  view  in  American  made 
instruments. 

In  the  construction  of  the  lens  system,  a  cement  is  used  which 
does  not  withstand  a  high  temperature.  The  silvered  surfaces 
of  the  prisms  and  hemispherical  lenses  are  very  promptly 
clouded  and  permantly  impaired  by  boiling,  making  this 
ordinary  method  of  sterilization  out  of  the  question.  As  some 
reliable  method  is  essential,  especially  in  instruments  constructed 
for  puposes  of  ureteral  catheterization,  the  asepticizing  quali- 
ties of  formaldehyde  vapor  have  been  utilized  with  such  com- 
plete success  that  it  has  come  to  be  considered  the  method  of 
choice.  The  cystoscopes  may  be  suspended  in  a  glass  jar 
or  air-tight  case  in  the  bottom  of  which  are  placed  tablets  of 
hexamethylen-tetramin  or  gauze  saturated  with  a  solution  of 
40  per  cent,  formalin.  If  the  latter  is  used,  calcium  chloride 
must  be  suspended  in  the  jar  in  order  that  it  may,  by  its  hygro- 
scopic qualities,  absorb  the  moisture  from  the  evaporation  of 
the  formalin  solution,  or  tablets  of  formalin  are  placed  in  the 
bottom  of  such  a  cabinet. 

Instruments  so  treated  are  thoroughly  sterile.  Before  using, 
the  cystoscopes  should  be  washed  in  sterile  water  to  remove  the 
irritating  formaldehyde.  Washing  in  ethereal  soap  and  alcohol, 
while  not  as  effective  as  the  method  described  above,  may  be 
used  with  a  fair  degree  of  satisfaction,  but  it  is  less  to  be  com- 
mended in  catheter-carrying  instruments. 


THE    CYSTOSCOPE  21 

The  woven-silk  catheters  used  for  ureteral  catheterization 
must  have  a  perfectly  smooth,  varnished  exterior  and  the  lumen 
of  the  catheters  must  be  thoroughly  patent.  On  account  of  the 
length  of  the  catheters  and  their  delicate  lumen,  coupled  with 
the  fact  that  formaldehyde  sterilization  has  a  tendency  to  soften 
and  destroy  the  varnish,  this  method  is  unsatisfactory.  After 
a  thorough  trial  of  the  different  methods  which  have  been  sug- 
gested we  have  finally  adopted  the  one  advocated  by  Casper — 
steam  sterilization.  The  sterilization  is  carried  out  as  follows: 
Each  catheter  is  wrapped  separately  in  gauze,  care  being  taken 
that  the  wrapping  is  so  carried  out  that  no  part  of  the  varnished 
surface  of  the  catheter  can  come  in  contact  with  any  other  part. 
In  other  words,  the  catheters  are  enclosed  full  length  in  a  gauze 
wrapping  of  about  three  layers.  The  catheters  so  wrapped  are 
placed  in  a  steam  sterilizer  and  the  steam  sterilization  contin- 
ued for  a  period  of  two  hours.  At  the  end  of  this  time,  the 
steam  is  cut  off  and  hot-air  sterilization  continued  for  fifteen 
minutes.  The  object  of  the  latter,  which  is  an  addition  to  the 
method  of  Casper,  is  to  drive  out  the  moisture  deposited  by 
the  steam.  The  catheters  are  removed  from  the  sterilizer  and 
placed  in  sterile  glass  jars,  thus  completing  the  technique. 

Where  quick  sterilization  is  required,  boiling  for  five  minutes 
in  a  supersaturated  solution  of  ammonium  sulphate  is  fairly 
satisfactory.  Washing  the  catheters  with  an  ethereal  soap  and 
immersing  them  for  a  few  minutes  in  a  3  per  cent,  formalin 
solution,  which  is  also  injected  through  the  catheters,  is  a  fairly 
reliable  method  where  steam  sterilization  is  impracticable. 
The  catheters,  of  course,  must  be  thoroughly  rinsed  in  sterile 
water  before  using. 


CHAPTER  III 
OPERATIVE  TECHNIQUE 

Subacute  or  chronic  symptoms  indicating  involvement  of 
the  bladder,  coupled  with  urinary  findings  corroborative  of  this 
involvement,  in  which  there  exists  the  slightest  doubt  as  to  the 
character  and  extent  of  the  responsible  factor  or  factors,  form 
a  direct  and  positive  indication  for  cystoscopy.  We  are  well 
aware  that  this  rather  sweeping  statement  is  at  variance  with 
the  teachings  of  former  writers  on  the  subject,  but  we  can  con- 
ceive of  no  conservative  means  other  than  cystoscopy  by  which 
accurate  and  comprehensive  knowledge  of  such  conditions  may 
be  obtained.  With  this  rule  as  a  working  basis,  sound  surgical 
judgment  and  careful  attention  to  technique  will  obviate  a 
detailed  and  exhaustive  resume  of  indications  pro  and  con. 

The  Preparation  of  the  Patient. — In  the  preparation  of  the 
patient  for  cystoscopy,  preliminary  urinary  antisepsis  should  be 
insisted  upon  where  feasible,  a  well-recognized  principle  in  all 
urethral  instrumentation.  The  lack  of  such  antisepsis  forms 
no  contraindication  to  cystoscopy. 

The  position  the  patient  should  assume  during  cystoscopy 
should  be  that  which  is  comfortable  for  the  patient  and  which 
will  permit  of  ease  in  manipulation  on  the  part  of  the  operator. 
Probably  the  most  satisfactory  position  for  both  patient  and 
operator  is  that  illustrated  in  Fig.  9.  This  position  is  applicable 
in  normal  cystoscopy  with  water  distention  instruments.  Where 
air-inflation  is  used,  the  Trendelenburg  position  is  of  great 
service,  if  not  absolutely  essential. 

The  external  genitals  should  be  thoroughly  cleansed  and 
contiguous  parts  isolated  from  the  field  of  operation  by  means 
of  sterile  towels.     The  bladder  should  then  be  catheterized. 


OPERATIVE    TECHNIQUE 


23 


While  general  anesthesia  is  seldom  necessary,  local  analgesia, 
though  not  absolutely  essential  in  the  majority  of  cases  requiring 


Fig.  9. — Application  of  local  anesthetic  (tablet  of  alypin)  through   tablet  depositor. 
Position  of  depositor  in  reaching  posterior  urethra. 

-cystoscopy,  is  a  source  of  much  comfort  to  the  patient  and 
greatly  facilitates  these  measures.  Indeed,  we  consider  in- 
sufficient  analgesia   to   be   probably    the   most   potent  factor 


24 


CYSTOSCOPY   AND    URETHROSCOPY 


operative  against  satisfactory  cystoscopy.     The  personal  equa- 
tion naturally  plays  an  important  role. 

For  obtaining  local  analgesia  many  methods  have  been  sug- 


FiG.  lo. — Introduction  of  the  cystoscope  into  the  anesthetized  urethra.      Patient  in 
proper  and  comfortable  position. 

gested  and  many  drugs  used.  The  deep  urethra  being  the  most 
sensitive  part  of  the  tract  is  that  part  which  requires  the  most 
analgesia.     To  obtain  this  the  instillation  of  some  analgetic 


OPERATIVE    TECHNIQUE  25 

solution  may  be  employed  or  the  author's  method  of  using 
alypin  tablets,  one  and  one-eighth  grain,  deposited  in  the  deep 
urethra  through  his  tablet  depositor,  may  be  made  use  of.  We 
have  caused  two  different  forms  of  this  depositor  to  be  made 
(Fig.  11),  one  for  the  male  urethra  and  one  for  the  female. 
In  our  hands  this  method  has  proved  by  far  the  most  satisfactory 
one.  The  method  is  as  follows:  The  depositor  is  inserted 
within  the  urethra  to  the  required  depth,  the  obturator  is  re- 
moved and  any  accumulated  urine  allowed  to  drain  away.  The 
tablet  is  placed  in  the  tube  and  the  obturator  is  inserted,  push- 
ing the  tablet  before  it  into  the  urethra.  By  gently  pushing  in 
and  pulling  out  the  depositor  with  the  obturator  fully  in  place  the 
softened  alypin  tablet  is  smeared  over  the  surface  and  analgesia 
is  readily  obtained.     This  procedure  may  be  repeated  as  often 


^^yjuJSiiiSiii 


Fig.  II. — Author's  urethral  tablet  depositor  for  male. 

as  is  necessary  to  obatin  the  required  degree  of  analgesia,  as  we 
have  never  seen  the  slightest  ill  effects  follow  the  use  of  al}'pin. 

Analgesia  having  been  obtained,  the  cystoscope  is  introduced 
and  an  irrigator  containing  clear  sterile  water  is  attached  to 
one  of  the  stop-cocks  on  the  sheath.  The  obturator  is  with- 
drawn and  the  bladder  flushed  out  through  the  sheath,  the  flow 
being  controlled  by  means  of  a  stop-cock  on  the  sheath.  This 
flushing  is  carried  out  until  the  washings  return  as  clear  as  may 
be  possible  under  the  conditions  present  (Figs.  17  and  18). 
Where  there  is  pronounced  hematuria  it  may  not  be  possible  to 
obtain  an  entirely  clear  medium  for  cystoscopy  and  we  must 
depend  upon  the  irrigating  cystoscope  to  clear  up  this  obscurity 
of  the  distention  medium. 


26 


CYSTOSCOPY   AND   URETHROSCOPY 


With  cystoscopes  of  a  non-irrigating  type,  with  a  fixed  lens- 
system,  the  above  technique  is  not  possible.  In  such  cases  it 
will  be  necessary  after  analgesia  has  been  obtained  to  insert  the 
catheter  and  to  irrigate  through  it,  after  which  the  cystoscope 
is  introduced. 

The  amount  of  distention  medium  used  depends  upon  the 
capacity  of  the  bladder  to  be  cystoscoped,  about  six  or  eight 
ounces  being  used  in  bladders  having  a  normal  capacity.  It  is 
perhaps  better  to  distend  the  bladder  with  a  telescope  inserted 
in  the  sheath,  for  if  the  bladder  be  under-  or  over-distended 
certain    distortions    in    the    cystoscopic   picture    occur    which 


Fig.  12. — Author's  urethral  tablet  depositor  for  female. 

may  prove  misleading  to  the  cystoscopist  of  small  experience 
and  tend  to  an  incorrect  interpretation  of  the  cystoscopic 
findings.  Distention  therefore  carried  out  with  the  cystoscope 
in  place  and  under  ocular  observation  is  the  more  accurate 
procedure. 

Before  inserting  the  cystoscope,  and  indeed  before  preparing 
the  patient,  the  cystoscopic  lamp  should  be  tested  and  the 
rheostat  turned  to  the  proper  point  for  good  illumination. 
This  preliminary  procedure  is  important  and  will  often  save 
much  embarrassment  to  the  operator  and  loss  of  time  in  replacing 


OPERATIVE    TECHNIQUE  27 

burned  out  lamps  or  correcting  other  details.  The  switch  is  then 
turned  off  and  is  not  again  turned  on  until  the  cystoscope  is  in 
the  bladder  and  the  operator  is  ready  to  begin  the  examination. 

In  the  selection  of  a  lubricant,  we  are  guided  to  a  certain 
extent  by  the  type  of  cystoscope  used.  If  instruments  of 
fixed  lens-system  type  are  used,  a  combination  of  glycerin  and 
gum  arabic  is  by  far  the  best  emollient  on  account  of  its  thorough 
miscibility  with  water  and  from  the  fact  that  it  in  no  way  tends 
to  cloud  the  lenses.  Where  sheath  instruments  are  used,  a 
sterile  preparation  of  Iceland  moss  may  be  used. 

The  Normal  Bladder. — For  purposes  of  systematic  ex- 
amination we  may  divide  the  bladder  into  the  two  sides,  the 
apex,  the  base  and  trigonum,  the  posterior  wall  and  the  region  im- 
mediately surrounding  the  internal  meatus.  While,  practically, 
most  of  the  lesions  of  interest  are  to  be  found  on  the  base  and 
trigonal  area  and  in  the  region  around  the  internal  urethral  mea- 
tus, systematic  search  must  include  all  of  the  areas  mentioned. 

In  using  cystoscopes  of  the  indirect  or  prismatic  view  type, 
the  first  area  under  observation  would  naturally  be  that  of  the 
apex  and  it  is  well  to  examine  this  area  before  proceeding 
further.  By  pushing  in  and  withdrawing  the  cystoscope  and 
by  elevating  and  depressing  the  instrument  each  point  will 
be  brought  into  focus. 

The  cystoscope  is  now  slowly  rotated  until  one  of  the  sides 
is  brought  into  view  when,  by  maneuvers  of  the  same  character 
as  those  described  above,  each  point  is  accurately  observed. 
Further  rotation  brings  into  view  the  base  and  trigonum  and 
the  orifices  of  the  ureters,  first  one  and  then  the  other  coming 
into  the  field  of  vision.  Still  further  rotation  brings  into  view 
the  other  side  of  the  bladder. 

For  observation  of  the  posterior  wall,  a  direct-view  instru- 
ment may  be  substituted  for  the  indirect*  and  for  observation 

*  We  cannot  agree  with  Fenwick  who  decries  the  necessity  for  a  direct-view  instru- 
ment, saying  that  by  proper  manipulation  it  is  possible  to  obtain  a  satisfactory  view  of 
the  posterior  wall  through  the  right-angle  view  cystoscope. 


28  CYSTOSCOPY   AND   URETHROSCOPY 

of  the  area  immediately  surrounding  the  internal  urethral  meatus 
an  instrument  having  a  retrospective  lens  must  be  used.  In 
using  cystoscopes  having  a  fixed  lens-system  these  changes 
necessitate  the  withdrawal  of  the  instrument  already  in  place 
within  the  bladder,  the  changing  of  the  conducting-cords  from 
the  rheostat  to  the  cysloscope,  the  readjustment  of  the  rheostat 
and  the  introduction  of  another  instrument  into  the  bladder. 
These  changes  consume  valuable  time  and  this  time  is  all  the 
more  valuable  should  the  patient  be  under  a  general  anesthetic 
or  the  distention  medium  evince  a  tendency  to  become  rapidly 
turbid.  The  use  of  the  sheath-type  instrument  minimizes  the 
time  lost  in  changing  from  one  lens-system  to  another,  as  it  is 
only  necessary  to  withdraw  one  telescope  from  the  sheath  and 
replace  it  by  another. 

The  cystoscopic  examination  having  been  completed,  the 
cystoscope  is  withdrawn  and  the  bladder  flushed  out  with  or 
without  a  full-sized  soft-rubber  catheter.  If  a  freely  irrigating 
or  sheath  instrument  be  used  this  may  be  accomplished  through 
the  instrument. 

Technique  of  Air-inflation  Cystoscopy.— For  purposes  of 
simple  cystoscopy,  air-inflation  of  the  bladder  in  either  the 
male  or  the  female  has  but  little  to  commend  it  and  is  to  be 
condemned.  As  a  distention  medium  air  is,  as  a  rule,  distinctly 
uncomfortable  to  the  patient  and  the  position  which  must  be 
assumed  by  the  patient  is  both  awkward  and  uncomfortable. 
On  account  of  the  absence  of  the  lens-system,  the  caliber  of  the 
cystoscope  is  decidedly  larger  than  where  water-distention  in- 
struments are  used ;  and  the  size  of  the  cystoscopic  field  is  greatly 
decreased.  The  presence  of  a  foreign  medium,  air,  in  the 
viscus  modifies  the  appearance  of  the  mucosa  so  that  the  picture 
obtained  under  air-inflation  is  essentially  different  from  that 
where  water  is  used.  Lastly,  it  is  impossible  under  air-inflation 
to  observe  the  anterior  wall  or  the  region  around  the  internal 
orifice.  In  the  female,  the  shortness  and  laxity  of  the  urethra 
permit  of  a  limited  observation  of  the  apex. 


OPERATIVE    TECHNIQUE  29 

In.  favor  of  air-inflation  cystoscopy  it  may  be  said  that  there 
are  certain  cases  of  extreme  hemorrhagic  conditions  in  which 
air-inflation  facilitates  the  examination.  But  even  in  cases  of 
extreme  hemorrhage,  free  irrigation  through  the  irrigating  cysto- 
scope  is  practically  always  sufficient  to  do  away  with  this  source 
of  annoyance. 

In  operative  cystoscopy,  which  will  receive  consideration  in 
another  chapter,  air-inflation  is  often  valuable. 

The  position  to  be  assumed  by  the  patient  in  air-inflation 
cystoscopy  must  be  that  which  will  permit  of  ready  ballooning 
of  the  bladder  by  the  air  and  which  will  at  the  same  time  drain 
the  accumulating  urine  away  from  the  distal  end  of  the  cysto- 
scopy In  the  male  these  essential  points  are  best  obtained  by 
the  exaggerated  Trendelenburg  position  and  in  the  female  by 
the  same  position  or  by  the  genupectoral  posture.  In  these 
positions  the  weight  of  the  abdominal  viscera  is  thrown  away 
from  the  bladder  and  the  accumulating  urine  gravitates  toward 
the  apex. 

The  bladder  is  catheterized  to  assure  its  being  thoroughly 
empty  and  the  sensibility  of  the  posterior  urethra  is  thoroughly 
obtunded.  This  thorough  analgesia  is  essential  for  the  reason 
that  any  spasmodic  efforts  on  the  part  of  the  bladder  or  involun- 
tary movements  on  the  part  of  the  patient  interfere  materially 
with  the  examination.  A  little  air  mixed  with  urine  and  ex- 
pelled into  the  cystoscopic  tube  by  a  spasmodically  contracting 
bladder  fills  the  tube  with  air-bubbles  which  must  be  removed 
with  the  aspirator  and  cotton- tipped  applicators  before  the  exami- 
nation can  proceed.  In  very  many  cases  general  anesthesia  will 
be  required  to  secure  the  relaxation  necessary  for  a  successful 
cystoscopy  by  means  of  air-distention. 

The  urethral  sensitiveness  having  been  obtunded,  the  bladder 
is  drained  of  any  fluid  which  may  have  accumulated  during  the 
production  of  anesthesia.  The  patient  is  placed  in  position  and 
the  cystoscope,  well  lubricated,  is  introduced  into  the  bladder. 
The  light,  having  previously  been  tested  and  adjusted,  is  turned 


30  CYSTOSCOPY   AND   URETHROSCOPY 

on.  In  the  female,  and  sometimes  in  the  male,  the  bladder  will 
be  seen  to  balloon  from  atmospheric  pressure. 

By  means  of  a  suitably  constructed  aspirator,  any  remaining 
fluid  is  aspirated  from  the  bladder.  If  forced  air-inflation  is 
necessary,  the  bevel  window  is  inserted  on  the  cystoscope,  the 
air-inflation  apparatus  is  attached  and  air  is  forced  into  the 
bladder. 

After  some  experimentation  a  few  years  ago  we  found  that 
heated  air  was  much  better  borne  by  the  bladder  than  air  at  the 
ordinary  room-temperature.  We  secured  this  necessary  heat 
by  placing  the  intake  of  the  inflating  bulbs  over  the  flame  of  an 
alcohol  lamp. 

The  Pawlik-Kelly  Method. — This  method,  which  is  only 
applicable  to  the  female,  was  first  devised  by  Pawlik,  of  Prague, 
and  popularized  by  Kelly,  of  Baltimore.  Its  simplicity  appeals 
to  the  general  surgeon  and  gynecologist;  and  while  it  is  not  to 
be  commended  in  cystoscopy  per  se,  it  is  of  value  in  certain 
intravesical  procedures  in  the  female. 

The  instruments  necessary  for  this  method  of  cystoscopy 
are  the  vesical  speculum  with  obturator  and  a  conical  dilator. 
Formerly,  the  bladder  was  illuminated  by  means  of  the  rays  of 
light  reflected  from  a  head-mirror  or  a  Washington-Isaac  lamp, 
but  since  the  introduction  of  the  low-amperage  mignon  lamp 
into  endoscopy,  the  source  of  illumination  is  contained  within 
the  tube.  For  the  disposal  of  the  accumulating  urine  in  the 
bladder,  Garceau,  of  Boston,  has  added  an  aspirating  attachment 
to  the  speculum. 

The  bladder  is  emptied  and  the  urethra  anesthetized.  The 
conical  dilator  is  introduced  into  the  urethra  and  by  a  rotary 
motion  the  urethra  is  gradually  dilated  up  to  the  mark  of  lo  on 
the  dilator.  This  means  an  average  dilatation  of  the  urethra 
of  one  centimeter. 

The  patient  is  placed  in  the  dorsal-hips-elevated  or  knee- 
chest  position.  In  ordinarily  thin  subjects  the  dorsal  posi- 
tion will  be   sufficient  for   the  atmospheric  ballooning  of  the 


OPERATR'E    TECHNIQUE  3 1 

bladder,  but  in  fat  women  the  knee-chest  posture  will  prove 
necessary. 

The  speculum  with  obturator  in  place  is  introduced  and  after 
removal  of  any  accumulated  urine,  inspection  or  other  maneuvers 
are  carried  out. 

The  Pawlik-Kelly  method  may  be  satisfactorily  carried  out 
without  preliminary  dilatation  by  the  use  of  the  short  anterior 
urethroscopic  tube.  We  have  utilized  the  Mark  aero-urethro- 
scope  for  this  purpose  with  perfect  satisfaction,  as  it  combines 
with  this  method  the  possibility  of  forced  air-inflation. 

The  objections  to  the  Pawlik-Kelly  method  as  a  purely 
cystoscopic  procedure  are  (i)  the  necessity  for  preliminary 
dilatation  of  the  urethra,  (2)  the  uncomfortable  position  of  the 
patient  and  (3)  the  incompleteness  of  the  view  obtained. 

The  Appearance  of  the  Normal  Bladder. — The  elements 
which  enter  into  the  cystoscopic  picture  and  which  require 
especial  observation  as  being  of  clinical  importance  are  (i) 
the  coloring,  (2)  the  vascularity  (3)  the  normal  luster  of 
the  epithelial  layer,  (4)  the  trigonum  and  (5)  the  ureteral 
orifices. 

The  Coloring.^ — The  normal  coloring  of  the  distended  bladder, 
which  in  reality  is  dependent  upon  the  vascularization  and  the 
integrity  of  the  epithelial  layer,  is  a  pinkish-straw  color  in  all 
parts  of  the  bladder  except  the  trigonal  area.  Here  it  is  reddish, 
sharply  marked  off  from  the  remainder  of  the  mucosa. 

The  Vascularity. — Scattered  over  the  mucosa  of  the  bladder 
are  numerous  arborescent  vessels  whose  minute  branches 
anastomose  with  great  constancy.*  Undue  distention  of  the 
bladder  with  fluid  obliterates  this  anastomosis,  making  it  unob- 
servable,  but  it  is  present  in  every  normal  bladder. 

These  vessels  arise  from  no  particular  points,  seemingly 
springing  from  general  trunks  situated  deeply  underneath  the 
mucosa.     They  vary  as  to  size  and  intensity  of  coloring.     Some 

*  Fenvvick  incorrectly  states   that  these  vessels  evince  no  tendency  toward  anas- 
tomosis. 


32  CYSTOSCOPY   AND    URETHROSCOPY 

are  deeply  red,  enough  to  suggest  their  being  venous  branches. 
The  retinal  appearance  suggested  by  Fenwick  is  marked. 

It  will  be  noted  that  there  are  considerable  areas  in  some 
bladders  which  are  apparently  devoid  of  these  branching  vessels. 
In  other  bladders,  this  vascularization  is  fairly  evenly  distributed. 
It  is,  as  a  rule,  more  marked  on  the  posterior  wall.  The  vas- 
cularization of  the  trigone  and  the  area  immediately  surround- 
ing this  portion  of  the  bladder  is  of  interest.  Often  the  trigone 
is  seen  to  be  bordered  with  numerous  delicate  vascular  branches 
very  closely  grouped.  In  fact,  these  branches  seem  to  lose 
themselves  in  the  greatly  increased  vascularity  which  character- 
izes the  trigone. 

Undue  distention  of  the  bladder  by  an  excess  of  fluid  in  the 
viscus  has  a  tendency  to  cause  a  disappearance  of  these  vessels 
and  a  consequent  anemic  appearance. 

The  Normal  Luster. — Covered  by  its  normal  epithelial  coat- 
ing and  with  a  normal  vascularization,  the  mucosa  of  the 
bladder  has  a  characteristic  luster  which  reflects  the  rays  of 
light  in  such  a  manner  as  to  give  a  general  and  even  illumination 
in  the  viscus.  Any  destruction  of  this  epithelial  layer  dulls  this 
reflecting  surface  to  such  an  extent  that  the  illumination  is 
markedly  interfered  with  and  we  have  the  so-called  "light- 
absorbing"  bladder. 

The  Trigonum. — This  area,  placed  at  the  anterior  portion  of 
the  bladder  base,  varies  greatly  in  different  individuals.  The 
sides  of  the  trigonum  vary  in  length  normally  from  one  to  one 
and  a  half  inches.  Though  usually  uniform  in  shape,  this  area 
is  by  no  means  always  so.  These  departures  from  the  uni- 
formity of  shape  of  the  normal  trigonum  have  been  classified  as 
"short"  and  "long"  trigona  by  Viertel.  To  these  common 
quasi-normal  conditions  may  be  added  that  one  in  which,  with 
an  irregularly  formed  trigonum,  one  ureteral  orifice  opens  almost 
directly  behind  the  meatus  internus. 

The  trigonal  area  is  very  slightly  elevated  above  the  sur- 
rounding  mucosa,    this   elevation   being   more   marked  at  the 


Fig.  13. — Anterior  cjstoscopic  view,  showing  (upper  portion)  normal  vesical  mucosa; 
(lower  portion)  half-moon  view  of  normal  internal  vesical  sphincter.     (Kneise.) 


Fig.  14. — Anterior  cystoscopic  view,  showing  transitional  mucosa  between  sphincter 
and  vesical  membrane.     Fine  radiating  arterioles.     (Kneise.) 


OPERATIVE    TECHNIQUE  T^;^ 

angles,  the  two  proximal  angles  being  raised  at  the  entrance  of 
the  ureters  to  form  the  montes  ureteri  and  the  distal  angle  being 
heaped  up  to  form  the  uvula.  This  elevation  of  the  trigonal 
angles  is  more  marked  in  the  incompletely  distended  bladder. 
Between  the  points  of  entrance  of  the  ureters  and  forming  the 
base  of  the  trigonum  is  the  interureteric  ridge  or  fold.  This  may 
be  so  pronounced  as  to  form  a  distinct  ridge,  though  ordinarily 
it  is  marked  by  but  slight  elevation.  Very  often  its  presence 
is  unmarked  by  any  sign  of  elevation. 

The  appearance  of  the  ureteral  orifices  is  by  no  means 
constant.  They  vary  from  fine,  hardly  discoverable  slits  in 
the  mucosa  to  readily  perceptible  depressions,  and  this  variation 
may  be  noted  between  the  ureters  of  the  two  sides.  Their 
edges  may  be  marked  by  a  finer  vascularization,  which  is  more 
noticeable  when  the  ureter  gapes  and  discharges  its  swirl  of 
urine.  The  localization  of  the  ureteral  openings  may  be  greatly 
facilitated  by  the  administration  of  methylene-blue  or  indigo- 
carmine  which  impart  to  the  urinary  jet  a  characteristic  coloring. 

The  coloring  of  the  trigone  varies  with  the  vascularity. 
Ordinarily  of  a  uniform  pinkish-red,  contrasting  strongly  with 
the  surrounding  mucosa,  this  area  is  readily  outlined,  but  in 
anemic  individuals  and  under  decided  distention  this  differentia- 
tion becomes  more  difficult. 

The  classical  description  of  the  trigonum  found  in  text-books 
and  in  monographs  describing  the  cystoscopic  appearance  of  the 
bladder  serves  rather  to  confuse  the  beginner  in  cystoscopy  than 
to  aid  him,  and  for  this  reason  we  have  avoided  it.  It  is  thor- 
oughly impracticable  to  describe  in  its  great  variations  of  shape, 
elevation  and  vascularity,  a  "normal"  or  ''typical"  trigonum. 
A  recognition  of  these  variations  within  normal  limits  must 
result  from  thorough  training  in  practical  cystoscopy. 

Fallacies. — Under  certain  conditions  of  over-  or  under- 
distention  of  the  bladder  with  fluid,  or  of  spasmodic  contraction 
of  the  detrusors,  cystoscopic  findings  which  are  apparently 
pathological  may  be  noted  and  are  very  often  misinterpreted  by 


34  CYSTOSCOPY   AND    URETHROSCOPY 

the  beginner  in  cystoscopy.  In  an  over-distended  bladder  or  in 
a  normally  distended  bladder  in  which  the  detrusors  are  con- 
tracting strongly  a  trabeculated  appearance  of  the  bladder 
surface  is  found  with  great  frequency.  The  explanation  of  this 
condition  is  obvious.  Such  apparent  trabeculation  is  un- 
associated  with  accompanying  pathological  changes. 

In  a  condition  of  under-distention,  the  angles  of  the  trigone 
become  prominent  and  under  an  improper  focus  the  prominence 
caused  by  the  heaped- up  uvula  may  assume  a  form  analogous 
to  certain  forms  of  prostatic  hypertrophy.  It  has  even  been 
mistaken  for  a  neoplasm. 

In  an  under-distended  bladder,  the  mucosa  becomes  wrinkled 
and  dimpled.  This  dimpling  may  be  mistaken  for  diverticula- 
tion  or  for  misplaced  ureteral  orifices. 

Blood  flowing  back  into  the  bladder  from  a  traumatized 
prostatic  urethra  and  clotting  may  deceive  the  novice  into  be- 
lieving he  is  observing  a  neoplasm.  A  stream  of  water  directed 
against  the  supposed  new-growth  through  the  irrigating  cysto- 
scope  will  dispel  this  illusion. 

In  introducing  the  fluid  used  for  distention  into  the  bladder, 
a  little  air  is  often  forced  in.  The  air-bubble  attaches  itself  to 
the  mucosa  and  will  be  noted  as  a  glistening  grape-like  body 
apparently  fixed  to  the  surface  of  the  bladder  at  the  apex  or 
anterior  wall.  It  should  offer  but  little  difficulty  to  proper 
interpretation. 

The  Interpretation  of  the  Cystoscopic  Picture. — It  must 
not  be  forgotten  by  the  beginner  in  cystoscopy  that  in  using'  the 
prismatic  or  hemispherical  lens-systems,  the  object,  or  field, 
under  observation  is  seen  as  an  inverted  image.  This  in- 
version of  the  image  is  quite  confusing  at  first  and  an  improper 
interpretation  of  the  picture  is  unconsciously  made.  To  over- 
come this,  it  is  necessary  that  the  cystoscopist  should  thoroughly 
familiarize  himself  with  the  picture  as  seen  through  the  lens- 
system.  This  proper  recognition  of  the  angles  can  be  readily 
secured  by  the  use  of  the  cystoscope  in  the  phantom^bladder 


OPERATIVE    TECHNIQUE 


35 


in  which  various  articles  such  as  calculi,  hairpins,  etc.,  have 
been  used.  Valentine  devised  an  exceedingly  simple  and  in- 
genious apparatus  for  studying  the  inverted  image  without  the 
use  of  the  cystoscope.  This  apparatus,  to  which  he  has  given 
the  name  of  Box  Phantom,  consists  of  a  small  square  box  at  the 
bottom  of  which  (Fig.  15)  is  a  schematic  circular  device,  sepa- 
rated into  four  segments. 

"  At  the  extreme  of  each  radius  is  a  figure  just  as  it  appears  on 
a  watch  dial.  In  two  segments  are  depicted  arrows  pointing  in 
various  directions,  a  key  and  a  hairpin.  Near  the  front  of  the 
picture  are  two  holes  intended  to  simulate  the  ureteral  orifices. 


Fig.  15. — Schematic  bottom  of  Valen-      Fig.     i6. — Valentine     cystoscopic     box 
tine     cystoscopic    box    phantom.      (New        phantom.     (New  York  Med.  Jour.) 
York  Med.  Jour.) 


The  right  side  of  the  box  has  a  metal  support  to  hold  the  lid  at 
an  angle  of  forty- five  degrees  to  its  open  surface.  The  inner 
surface  of  the  lid  has  a  mirror.  In  the  front  of  the  box  is  a  hole, 
representing  the  urethral  lumen."* 

A  late  improvement  in  the  Universal  cystoscope  consists  of 
an  ocular  lens  fitting  at  will  on  the  eye-piece  of  each  telescope 


*  Ferd.  C.  Valentine:     Aids  to  Cystoscopic  Practice,  N.  Y.  Med.  Jour.,  June  6, 
1903. 


36  CYSTOSCOPY   AND    URETHROSCOPY 

and  correcting  the  inversion  and  placing  all  images  in  their 
correct  position.* 

The  phantom  is  used  by  holding  it  in  the  hand  and  ob- 
serving the  reflected  image  on  the  mirrored  lid.  Various  man- 
ipulations may  be  tried  by  means  of  a  probe  or  similar 
instrument  introduced  through  the  hole  representing  the 
urethral  opening.  The  operator  is  guided  in  his  manipula- 
tions by  the  reflection  noted  in  the  mirror. 

In  studying  the  size  of  the  image,  as  observed  through  the 
cystoscope,  the  cystoscopist  must  keep  in  mind  the  fact  that  the 
area  under  observation  increases  in  size  as  the  lens-system  is 
carried  away  from  it.  With  this  increase  in  observed  area 
there  is  a  proportionate  loss  of  detail.  Vice  versa,  if  the  lens- 
system  is  moved  toward  the  area  under  observation,  the  details 
become  larger  and  more  distinct.  According  to  Casper,  the 
natural  size  of  an  object  is  seen  at  a  distance  of  about  two  centi- 
meters, but  this  necessarily  depends  upon  the  telescope  used  and 
its  focal  distance. 

In  order  to  properly  interpret  the  size  of  objects  observed 
cystoscopically,  the  cystoscopist  must  avail  himself  of  practical 
experience  in  observing  objects  of  known  size.  By  carefully 
observing  the  ratio  between  the  size  and  clearness  of  detail  of 
the  object  observed,  subsequent  distortion  of  the  image  in 
actual  cystoscopy  is  avoided. 

*In  the  latest  model  (19 14)  of  the  same  instrument  the  image  is  corrected  in  all 
telescopes,  obviating  the  necessity  of  applying  a  correcting  eye-piece. 


CHAPTER  IV 
URETERAL  CATHETERIZATION 

While  the  necessity  for  the  segregation  of  the  two  urines  had 
long  been  recognized,  it  was  not  until  1874  that  the  first  practical 
attempt  at  segregation  was  made.  In  this  year,  Tuchman,  of 
the  German  hospital  in  London,  utilizing  an  instrument 
somewhat  resembling  a  lithorite  was  enabled  to  compress 
the  vesical  extremity  of  one  ureter  and  collect  the  urine  com- 
ing from  the  opposite  kidney.  The  crudity  and  uncertainty 
of  this  procedure  was  sufficient  to  condemn  it  as  impracticable. 

In  the  following  year,  Simon  endeavored  to  catheterize  the 
female  ureter  by  guiding  the  catheter  along  a  finger  introduced 
into  the  bladder  through  the  previously  dilated  urethra.  The 
over-stretching  of  the  sphincter  necessitated  in  this  procedure 
resulted  in  quite  severe  tears  and  incontinence  in  some  cases. 

About  this  time,  Hegar  proposed  temporary  ligation  of  the 
ureter,  the  ligature  to  be  applied  through  the  anterior  vaginal 
wall.  Some  years  later,  a  method  of  ligating  the  ureter  for  the 
purpose  of  segregation  was  devised  by  Sanger.  In  this  method 
the  hgation  was  applied  through  an  abdominal  incision  such  as 
was  employed  for  ligating  the  common  iliac  artery.  Hegar' s 
method  w^as  again  taken  up  in  1886  by  Warkalla  who  proposed 
to  pass  a  threaded  needle  under  the  ureter  and  to  occlude  the 
ureter  by  traction  upon  this  ligature. 

In  1 88 1,  Griinfeld  utilized  his  vesical  endoscope  and  under 
the  guidance  of  the  eye  passed  a  catheter  alongside  the  speculum 
into  the  bladder  and  thence  into  the  ureter.  Two  years  later, 
1883,  Newman  of  Glasgow  utilized  an  incandescent  lamp  cysto- 
scope  for  the  same  purpose. 

In  1880,  Pawlik  devised  his  method  of  "fishing"  for  the 
ureteral  orifices  in  the  female  bladder  without  endoscopy  or 

37 


;^S  CYSTOSCOPY   AND   URETHROSCOPY 

dilatation  of  the  urethra.  Pawlik's  method  was  based  upon 
certain  anatomical  landmarks  observed  on  the  stretched  anterior 
wall  of  the  vagina.  These  landmarks  were  prominences  on 
the  mucosa  corresponding  to  the  boundaries  of  the  vesical  tri- 
gone. Having  recognized  these  landmarks  both  by  sight  and 
touch,  the  catheter,  which  was  of  metal,  was  passed  through 
the  urethra  into  the  bladder  which  was  distended  with  two 
hundred  cubic  centimeters  of  fluid.  The  tip  of  the  catheter  was 
directed  against  the  angle  of  the  trigone  and  the  ureteral  orifice 
was  fished  for. 

Later,  about  1886,  Pawlik  devised  his  method  of  catheteriz- 
ing  the  femiale  ureter  through  an  open  endoscopic  tube.  By 
means  of  the  exaggerated  Trendelenburg  or  genupectoral  posi- 
tion air  entered  the  tube  and  distended  the  bladder  from 
atmospheric  pressure. 

Howard  Kelly,  of  Baltimore,  took  up  the  method  of  Pawlik 
and  by  his  earnest  advocacy  of  it  did  much  to  popularize  and 
advance  catheterization  of  the  ureters  in  the  female. 

Various  other  methods  for  segregation  have  been  suggested 
and  later  discarded.  It  suffices  to  mention  the  methods  of  Sands, 
Wier,  Heuser  and  Silberman.  In  Sand's  method  the  ureter  was 
compressed  by  digital  pressure  exerted  through  the  rectum  in  the 
male  and  the  vagina  in  the  female.  Wier  proposed  to  compress 
the  ureter  against  the  pelvis  by  means  of  a  Davy's  rod  introduced 
into  the  rectum.  Heuser  proposed  by  means  of  a  sort  of  padded 
vise  to  compress  the  ureter  through  the  abdominal  wall — a 
thoroughly  absurd  and  unsurgical  procedure.  Intravesical 
compression  of  the  ureteral  orifice  by  means  of  a  rubber  balloon 
attached  to  a  catheter,  through  which  quicksilver  was  introduced 
into  the  balloon,  was  the  basis  of  the  method  of  Silberman. 

The  modification  of  the  lens-system  cystoscope  for  the 
purposes  of  ureteral  catheterization  has  received  attention 
in  the  preceding  chapter. 

In  1898,  Harris,  of  Chicago,  devised  his  "segregator"  by 
means  of  which  a  sort  of  water-shed  was  created  on  the  base  of 


URETERAL   CATHETERIZATION  39 

the  bladder,  from  each  side  of  which  was  collected  the  sepa- 
rate urines  from  the  two  ureters.  In  the  past  few  years  two 
other  separators  have  appeared — those  of  Luys  and  Cathelin 
of  France. 

The  fallacies  of  the  segregator  are  many  and  its  use  as  an 
accurate  diagnostic  measure  is  not  to  be  countenanced  in  the 
face  of  the  overwhelming  evidence  in  favor  of  ureteral  cathe- 
terization. Some  of  the  most  potent  arguments  against  its 
employment  follow: 

(i)  Its  use  is  attended  with  more  discomfort  than  ureteral 
catheterization. 

(2)  With  the  kidney  infection  there  may  be  a  vesical  in- 
volvement trailing  over  to  the  opposite  side  which  may  readily 
confuse  the  investigator. 

(3)  A  bladder  stone  or  new-growth  may  prevent  segregation 
of  the  ureteric  areas  with  a  consequent  mixing  of  the  two  urines. 
The  same  result  may  ensue  in  a  trabeculated  bladder  or  in 
intravesical  prostatic  encroachment. 

(4)  The  ureteral  orifices  may  be  congeni tally  misplaced. 
Kiimmel  reports  a  case  in  which  urine  was  secured  from  the 
right  side  by  the  use  of  a  Luys  segregator  though  the  right 
kidney  had  been  previously  removed. 

The  Purposes  of  Ureteral  Catheterization.^The  indications 
for  and  the  purposes  of  ureteral  catheterization  as  outlined  by 
us  in  the  Annals  of  Surgery*  for  January,  1903,  are  sufficiently 
comprehensive.     They  are  as  follows: 

Diagnosis. — A.  To  locate  the  origin  of  pus,  blood,  tuberculous 
products  or  bacilli,  the  various  pyogenic  infections,  abnormally 
desquamated  epithelium,  etc.,  as  to  whether  they  come  from 
(i)  the  bladder,  (2)  the  right  ureter,  (3)  the  left  ureter,  (4)  the 
right  kidney,  (5)  the  left  kidney,  (6)  the  right  or  the  left  peri- 
renal space,  and  communicating  with  the  corresponding  kidney 
or  ureter. 

*  Ureter  Catheterization:  Its  Purposes  and  Practicability.  Bransford  Lewis, 
Annals  of  Surgery,  Jan.,  1903. 


40  CYSTOSCOPY   AND   URETHROSCOPY 

B.  To  recognize  and  locate  obstructive  conditions  in  the 
right  or  left  ureter  from  (i)  stricture,  (2)  stone,  (3)  adjacent 
tumors,  (4)  bend  or  kink  in  the  ureter  from  movable  or  dis- 
located kidney,  (5)  valvular  junction  of  ureter  and  its  pelvis. 

C.  To  determine  (i)  the  presence  of  two  kidneys;  (2)  if 
only  one,  which  is  absent. 

D.  To  determine  the  number  of  ureters  present. 

E.  To  determine  the  functional  activity  of  each  kidney 
separately  and  relatively,  with  respect  to  its  excretion  of  urea, 
albumin,  quantity  of  urine,  the  specific  gravity,  etc. 

F.  To  determine  the  size  and  capacity  of  each  kidney  pelvis 
with  respect  to  (i)  hydronephrosis,  (2)  pyonephrosis,  (3)  total 
obliteration  of  kidney  secreting  tissue. 

G.  If  there  be  kidney  disease  present,  to  determine  (i) 
if  only  one  kidney  is  affected  or  both;  (2)  if  only  one,  which 
the  affected  one;  (3)  if  both,  which  is  the  one  more  affected; 
(4)  if  removal  of  the  worse  one  be  advisable,  is  the  other  one 
able  to  carry  on  kidney  function  sufficiently?  (5)  if  removal 
of  one  be  advisable,  and  the  other  is  capable  of  supporting  life, 
will  the  operation  remove  the  infection  from  the  body,  removing 
the  possibility  of  dissemination  or  recontamination? 

Treatment. — A.  To  enlarge  narrowings  or  stricture  at  (i) 
the  ureter  openings  or  (2)  in  the  channels  of  the  ureters.  By 
facilitating  drainage  through  the  increased  ureter  caliber,  thus  ob- 
tained, to  assist  in  the  improvement  of  pyelitis  or  pyonephrosis, 
unilateral  or  bilateral. 

B.  To  irrigate  and  medicate  (i)  the  ureters,  (2)  the  kidney 
pelvis  of  one  or  both  sides. 

C.  To  assist,  by  anesthetizing  and  enlarging  the  ureter 
opening,  the  passage  through  it  of  a  calculus  or  a  plug  of  pus, 
blood,  etc.,  and  by  such  analgesia  to  relieve  renal  colic. 

D.  To  use  the  ureter,  after  it  is  catheterized,  as  a  guide  in 
certain  abdominal  and  pelvic  operations. 

E.  By  prolonged  catheterization  of  a  ureter  to  assist  in  the 
cure  of  a  ureteral  fistula. 


URETERAL    CATHETERIZATION 


41 


The  Choice  of  Method. — Whether  the  ureters  are  to  be 
catheterized  by  the  direct  (Brenner)  or  indirect  (Nitze)  method 
is,  in  the  majority  of  cases,  a  mere  matter  of   the  operator's 


Fig.  17. — Irrigation  of  bladder  through  the  cystoscope  sheath.     Thumb  covering  the 
escape,  water  flowing  into  the  bladder. 

personal  preference  based  upon  his  training  in  the  technique  of 
the  two  methods.     In  a  general  way  it  may  be  said  that  cathe- 


42 


CYSTOSCOPY    AND    URETHROSCOPY 


terization  with  the  direct  lens-system  is  the  method  of  choice 
where  applicable,  but  there  are  cases  in  which  one  is  com- 
pelled to  resort  to  the  indirect  method 


Fig.  1 8. — Irrigation.  Thumb  removed  and  water  escaping.     Patient  comfortable. 

The  reasons  for  giving  preference  to  the  direct  method  have 
been  very  ably  presented  by  Kolischer  and  Schmidt  (Jour, 
of  A.  M.  A.,  June  4,  1904).     Summed  up  they  are  as  follows: 


URETERAL    CATHETERIZATION  43 

(i)  The  distance  between  the  opening  of  the  catheter 
channel  of  the  cystoscope  and  the  orifice  of  the  ureter  is  much 
less  in  the  direct  method  than  in  the  indirect  (Figs.  24  and  29), 
and  the  direction  of  approach  of  the  catheter  is  in  the  same 
line  as  the  ureteral  canal.  On  account  of  the  extreme  flexi- 
bility of  the  ureteral  catheters,  the  shortness  of  the  space  to 
be  bridged  over  in  using  the  direct  method  is  a  distinct 
advantage. 

(2)  The  tension  on  the  suspensory  ligament  and  the  genitalia 
is  much  less  when  the  ureteral  opening  is  in  view  with  the 
Brenner  type  of  instrument. 

(3)  The  withdrawal  of  the  direct  lens-system  cystoscope 
with  the  ureteral  catheters  in  place  is  readily  accomplished 
without  disturbing  the  catheters.  Bierhoff's  modification  of 
the  Nitze-Albarran  instrument  has  made  this  withdrawal  pos- 
sible where  the  indirect  method  of  catheterization  is  pursued. 
In  the  later  models  of  our  new  Universal  Cystoscope,  the  with- 
drawal of  the  indirect  lens- system  and  the  removal  of  the 
sheath  leaving  the  catheters  in  place  is  readily  accomplished. 

In  favor  of  the  indirect  method,  there  is  but  one  argument 
which  holds  good  in  normal  catheterization  of  the  ureters: 
The  ureteral  openings  are  more  readily  discoverable  in  cystos- 
copy by  the  indirect  method. 

In  some  forms  of  prostatic  hypertrophy  or  in  precipitate 
bladders  (Fig.  22)  and  in  some  diseased  conditions  of  the 
ureteral  meatus  catheterization  by  the  indirect  method 
becomes  necessary.  Kolischer  and  Schmidt,  in  discussing  the 
first  two  of  these  conditions,  say  that  the  necessity  for  using  the 
indirect  method  may  be  obviated  by  intrarectal  lifting  of  the 
bladder  base.  While  this  may  be  accomplished  in  some  cases, 
we  question  its  utility  in  the  majority  of  cases  of  this  character 
and  certainly  prefer  not  to  subject  our  patients  to  such  an 
awkward  and  uncomfortable  procedure. 

Selection  of  Ureteral  Catheters. — The  catheters  for  catheter- 
izing  the  ureter  should  fulliU  certain  requirements. 


44  CYSTOSCOPY   AXD    URETHROSCOPY 

(i)  They  must  be  of  the  best  grade  of  woven  silk.  Their 
surface  must  be  without  flaw  or  roughness. 

(2)  They  must  be  flexible,  yet  stiff  enough  to  be  readily 
threaded  through  the  catheter  channels  in  the  cystoscope  with- 
out evincing  a  tendency  to  bending. 

(3)  Their  lumen  must  be  thoroughly  patent  and  of  suf- 
ficient caliber  to  assure  drainage.  The  eye  of  the  catheter 
must  be  of  sufficient  size. 

(4)  They  must  be  long  enough  to  permit  their  introduction 
into  the  ureter  as  far  as  the  kidney  pelvis  if  such  procedure  is 
desirable. 

As  regards  the  size  of  the  catheter,  the  shape  of  the  tip  and 
the  placing  of  the  eye,  we  must  be  guided  by  the  character  of 
the  work  to  be  done  and  the  conditions  met  with  in  the  ureter. 
The  size  of  the  catheter  should  be  as  large  as  compatible  with 
the  catheter  channels  in  the  cystoscope  and  the  ureter  to  be 
catheterized.  Thus,  in  an  unobstructed  ureter  and  with  the 
average  catheterizing  cystoscope,  a  No.  6,  French,  may  be  used. 
It  is  possible  in  some  cystoscopes  to  use  a  No.  7,  French. 

In  the  vast  majority  of  instances  in  which  catheterization  of 
the  ureter  is  demanded,  a  catheter  having  the  ordinary  blunt, 
rounded  tip  is  preferable.  In  some  cases  of  stricture  of  the 
ureter,  the  olive-tipped  catheters  are  of  service. 

For  ordinary  diagnostic  measures,  a  laterally  placed  eye  fills 
all  requirements.  Where  lavage  of  the  kidney  pelvis  or  ureter 
is  desirable,  a  catheter  having  a  centrally  placed  eye  is  preferable 
though  not  absolutely  essential.  The  so-called  "whistle-tip" 
catheters  have  proven  excellent  for  both  diagnosis  and 
lavage. 

For  determining  ureteral  length  or  the  accurate  location  of 
obstructions  in  the  ureter,  the  zebra  ureteral  catheters  are  of 
great  service.  These  catheters  are  graduated  into  centimeters, 
alternately  black  and  yellow  or  orange,  and  by  observing  the 
catheter  as  it  is  pushed  up  into  the  ureter,  an  accurate  idea  of 
distances  may  be  obtained.     Ayres,  of  New  York,  has  caused 


URETERAL    CATHETERIZATION  45 

such  catheters  to  be  constructed  having  each  fifth  centimeter 
colored  red,  making  the  measurement  more  easily  observed. 

For  X-ray  work,  a  catheter  containing  a  wire  stylet  may  be 
utilized.  Leaded  ureteral  bougies  and  hollow  catheters  filled 
with  insoluble  bismuth  salts  have  been  made  use  of  for  the 
same  purpose.  Lately,  hollow  catheters  having  bismuth  in- 
corporated in  their  walls  have  been  used  with  satisfactory  results. 

TECHNIQUE 

Direct  Method. — The  cystoscope  and  catheters  are  sterilized 
in  accordance  with  the  technique  described  in  aprevious  chapter. 
The  cystoscope  is  inserted  and  with  the  bladder  distended,  the 
catheters  in  place  in  the  catheter  channels  of  the  cystoscope, 
the  interureteric  ridge  is  searched  for  and  followed  to  one 
angle  of  the  trigonum.  It  is  in  this  neighborhood  that  we  may 
expect  to  find  the  orifice  of  the  ureter.  In  the  hands  of  the 
practised  cystoscopist,  this  methodical  search  for  the  orifice  of 
the  ureter  is  seldom  necessary. 

If  a  slit  or  dimple  in  the  mucosa  is  observed  it  is  kept  under 
observation  to  determine  whether  or  not  it  is  the  ureteral  meatus. 
If  we  are  observing  the  orifice,  in  a  few  seconds  the  mons  ureteris, 
upon  which  the  orifice  is  located,  will  be  seen  to  swell  up,  the  slit 
gapes  and  a  swirl  of  urine  issues  forth.  To  facilitate  the  finding 
of  the  ureteral  orifices,  different  drugs  which  impart  a  character- 
istic coloring  to  the  urine,  such  as  methylene-blue  or  indigo- 
carmine,  may  be  employed.  The  colored  urine  is  emitted  in  a 
greenish-blue  or  purplish  swirl  which  is  readily  noted  in  the 
clear  distention  medium.  Keeping  this  slit  under  observation, 
the  catheter  corresponding  to  the  orifice  is  pushed  on  until  it  is 
seen  to  emerge  into  the  cystoscopic  field.  The  tip  is  made  to 
penetrate  the  ureteral  orifice  and  the  catheter  is  now  slowly 
pushed  onward  with  a  slight  rotary  motion  until  it  has  traversed 
the  desired  distance  within  the  ureter.  The  catheter  must  be 
kept  constantly  under  observation  during  this  maneuver  in  order 


46 


CYSTOSCOPY   AND    URETHROSCOPY 


that  we  may  be  assured  that  it  is  pursuing  its  course  up  the  ureter 
and  that  it  has  met  no  obstruction.     This  is  important. 

The  catheter  having  been  pushed  in  the  desired  distance, 


Fig.   19. — Observation  cystoscopy.      With  bladder  full  of  water,  telescope  inserted,  light 
turned  on,  operator  views  the  interior  of  the  organ  and  its  contents. 

search  is  now  made  for  the  orifice  of  the  other  ureter  and  the 
same  procedure  carried  out.     It  is  usually  a  very  easy  matter  to 


URETERAL    CATHETERIZATION 


47 


locate  the  other  orifice  by  the  simple  process  of  following  the 
interureteric  fold  directly  across  from  the  ureter  which  has 


Fig.  20. — Ureteral  catheterization  (direct  method).  Insertion  of  the  catheter  into 
left  orifice  by  right  hand;  cystoscope  held  by  the  left.  Both  catheters  supported  by  an 
assistant. 

already  been  catheterized,  but  the  possibility  of  an  asymmetrical 
placing  of  the  orifices  must  be  always  kept  in  mind. 


48 


CYSTOSCOPY   AND    URETHROSCOPY 


With  both  catheters  in  place,  the  cystoscope  is  withdrawn, 
leaving    the   catheters   in   situ.     The   manner   in   which    this 


Fig.  21. — Ureteral  catheterization  (direct  method).  Insertion  of  catheter  into  right 
orifice  by  left  hand.  Catheters  may  be  supported  on  the  shoulders  of  operator,  if  a 
sterile  gown  be  worn. 

maneuver  is  accomplished  depends  upon  whether  the  cathe- 
terization is  done  with  a  fixed  lens-system  instrument  or  with 


URETERAL    CATHETERIZATION  49^ 

the  sheath  tj^De  of  cystoscope.     In  the  former,  the  catheters  must 
be  threaded  in  at  the  same  rate  that  the  cystoscope  is  removed 


Fig.  22. — Showing  inaccessibility  of  ureteral  catheterization  by  direct  method  in  the 
presence  of  precipitate  bladder  or  enlarged  (overhanging)  prostate. 


Fig.  23. — Direct  catheterization,  side  view.    Left  ureteral  orifice  in  range  of  view  of 
direct  catheterizing  telescope. 

in  order  that  their  position  in  the  ureters  may   remain  un- 
changed.    With  the  sheath  instruments,  the  lens-system  con- 
4 


50 


CYSTOSCOPY   AND   URETHROSCOPY 


taining  the  catheter  channels  may  be  withdrawn  sHghtly  from 
the  sheath  and  the  catheters  disengaged  from  their  channels 
(see  Fig.  36)  and  left  lying  loose  within  the  sheath.  The 
distention  fluid  is  allowed  to  run  out  through  the  sheath  which 
can  now  readily  be  withdrawn  without  disturbing  the  catheters. 
The  ends  of  the  catheters  are  now  cleansed  with  a  moist  piece 
of  gauze,  dried  with  a  piece  of  sterile  gauze  and  the  first  few 
drops  of  the  drainage  are  allowed  to  escape.     If  drainage  is  not 


Fig.  24. — Direct  catheterization,  side  view.      Catheter  inserted  into  left  ureter. 

established  within  a  reasonable  time,  the  eye  of  the  catheter  is 
probably  occluded  by  the  ureteral  mucosa  or  a  plug  of  mucus 
or  pus  or  a  clot  of  blood.  The  injection  of  one  or  two  cubic 
centimeters  of  sterile  water  through  the  catheter  serves  to  es- 
tablish the  flow.  The  catheter  from  the  right  ureter  is  drained 
into  a  sterile  bottle  or  test-tube  marked  "Right"  and  that  from 
the  left  ureter  into  a  similar  bottle  or  tube  labeled  "Left."  If 
the  eye  of  the  catheter  lies  within  the  ureter,  the  drainage  has  the 
peculiar  characteristics  of  the  ureteral  spurt.  There  will  be  the 
expulsion  of  a  few  drops  of  urine  at  fairly  regular  intervals, 
varying  from  four  seconds  to  as  many  minutes.  If  the. eye  of 
the  catheter  lies  within  the  kidney  pelvis,  this   intermittent 


URETERAL    CATHETERIZATION  5 1 

spurt  is  absent,  the  urine  coming  in  a  steady  drop,  drop,  drop. 
The  two  catheters  do  not  discharge  their  contents  synchronously, 
nor  are  the  intervals  between  spurts  the  same  on  both  sides. 

In  order  to  avoid  any  possibility  of  confusing  the  two  cathe- 
ters, they  should  be  of  different  colors.  It  is  w^ell  to  establish 
a  jQxed  rule  of  using  a  certain  color  for  the  right  ureter  and  a 
certain  color  for  the  left.     By  adhering  to  this  rule,  all  possible 


Fig.  25. — Direct  catheterization;  cystoscopic  view.     Approach  of  catheter. 

confusion  arising  from  this  cause  is  obviated.  We  have  made 
it  a  rule  to  use  a  light-colored  catheter  for  the  left  side  and  a  dark 
catheter  for  the  right. 

Before  the  catheters  are  placed  in  the  lens-system,  it  is  our 
practice  to  fill  their  lumen  with  sterile  water  and  the  catheters, 
so  filled,  are  plugged  at  their  external  opening  with  ordinary 
commercial  pins.  These  plugs  are  not  removed  until  the  cathe- 
ters are  in  the  ureters,  thus  preventing  any  contamination  from 
the  bladder  fluid. 


52 


CYSTOSCOPY   AND   URETHROSCOPY 


Kolischer  and  Schmidt  have  suggested  lubrication  of  the 
ureteral  catheter  with  glycerin  or  a  preparation  of  tragacanth 
in  order  to  facilitate  its  passage  up  the  ureter  and  to  reduce 
trauma.  The  idea  of  lubrication  is  an  excellent  one  but  the  use 
of  either  of  the  above  lubricants  is  fallacious  as  they  are  thor- 
oughly miscible  with  water  and  in  the  passage  of  the  catheter 
from  the  cystoscope  into  the  ureter  it  must  pass  through  the 
water  used  for  distention  and  the  lubrication  becomes  practically 


Fig.  26. — Direct  catheterization.     Catheter  inserted  into  left  ureter. 

nil.  We  have  made  use  of  sterile  oil  for  this  purpose  but  the  oil 
has  the  disadvantage  of  contaminating  the  drainage  and  is  open 
to  the  objections  urged  against  oily  lubricants. 

When  sufficient  urine  has  been  obtained  through  the  cathe- 
ters, they  are  withdrawn  from  the  ureters.  It  is  a  wise  precau- 
tion to  inject  a  few  cubic  centimeters  of  a  5  per  cent,  solution 
of  argyrol  through  the  catheter  as  it  is  being  withdrawn. 

Indirect  Method. — If  it  be  of  the  Nitz  type  the  cystoscope 
containing  the  catheters  within  the  channels  provided  for  them 


URETERAL   CATHETERIZATION 


S3 


is  inserted  into  the  distended  bladder  and,  the  light  being  turned 
on,  the  cystoscope  is  turned  until  the  angle  of  the  trigonum 
comes  into  view.  The  ureteral  orifice  is  located  and  the  cor- 
responding catheter  is  made  to  emerge  into  the  cystoscopic 
field.  By  manipulation  of  the  lever  controlling  the  angle  of 
the  catheter  it  is  made  to  take  the  direction  of  the  orifice  of  the 
ureter  and  inserted  in  the  manner  described  under  catheteriza- 
tion by  the  direct  method. 


Fig.  27. — Direct  catheterization. 


Both  catheters  in  place,  ready  for  withdrawal  of 
cystoscope. 


The  catheter  having  been  inserted  the  desired  distance,  the 
other  ureter  is  located  and  similarly  catheterized. 

In  using  the  Casper  slide-bar  principle,  the  catheter  after  its 
insertion  into  the  ureter,  is  thrown  out  into  the  urethra  and  the 
second  catheter  inserted.  Both  ureters  being  catheterized,  the 
second  catheter  may  be  thrown  out  into  the  urethra  and  the 


54 


CYSTOSCOPY   AND   URETHROSCOPY 


cystoscope,  being  turned  until  its  beak  presents  upward,  may 
be  withdrawn  from  the  bladder.     This  cannot  be  accomplished 


Fig.  28. — Indirect  catheterization,  side  view.     Left  ureteral  orifice  in  view,   catheter 
emerging  from  ureteral  channel  and  coming  into  view  of  operator. 


Fig.  29. — Indirect  catheterization.     Catheter  inserted  into  left  ureter. 

without  disturbing  the  position  of  the  catheters  in  the  ureters  to 
a  certain  degree.  It  is  often  found  difhcult  to  effect  this 
maneuver. 


URETERAL    CATHETERIZATION 


55 


Where  the  Nitze  or  Albarran  instruments  are  used,  it  is 
usually  necessary  to  leave  the  instrument  in  situ  while  the  cathe- 


FiG.  30. — Indirect  catheterization,  side  view.     Catheter  about  to  enter  left  ureteral 
orifice;  direction  controlled  by  (a)  angle  of  cystoscope,  and  (b)  the  lever. 


Fig.  31. — Indirect  catheterization,  side  view.  Catheter  inserted  into  left  ureter. 
Angulation  of  cystoscope  shown  by  dotted  lines  (first  position)  and  solid  lines,  second 
position — for  catheterization. 

ters  are  draining,  on  account  of  the  impracticability  of  turning 
the   cystoscope  without   materially    disturbing   the   catheters. 


56  CYSTOSCOPY   AND   URETHROSCOPY 

Bierhoff's  modiii cation  makes  this  turning  and  the  subsequent 
withdrawal  of  the  cystoscope  possible. 

In  using  the  indirect  catheterizing  telescope  of  our  universal 
cystoscope,  the  catheterizing  telescope  may  be  withdrawn  from 
the  sheath  as  in  the  direct  catheterizing  instrument,  leaving  the 
catheters  undisturbed  within  the  ureters. 


Fig.  32. — Indirect  catheterization  of  left  ureter.     Approach  of  catheter. 

The  subsequent  technique  is  the  same  as  that  employed  in 
catheterization  by  the  direct  method  only  it  must  be  remembered 
that  the  beak  is  turned  downward  and  must  be  again  turned 
upward  before  the  sheath  is  removed.  In  removing  the  indirect 
telescope  after  the  catheters  are  in  place  within  the  ureters  the 
following  steps  must  be  employed:  (i)  Lower  the  lever  to  its 
lowest  point;  remove  the  telescope  sufficiently  to  grasp  the 
catheters  and  disengage  them  from  the  proximal  ends  of  the 
catheter  channels  letting  them  lie  loose  within  the  sheath  and 
then  complete  the  removal  of  the  cystoscope;  (3)  rotate  the 


URETERAL    CATHETERIZATION  57 

sheath  upon  its  own  axis  so  as  to  bring  the  beak  upward  and 
remove  the  sheath  as  in  direct  catheterization. 

Catheterization  under  Forced  Air-inflation. — This  method 
of  catheterization  which  did  much  to  popularize  the  procedure — 
especially  in  America — has  practically  been  relegated  to  the 
past.     Catheterization  is  by  the  direct  method. 

The  cystoscope  containing  the  ureteral  catheters  in  the 
catheter    channels   is   inserted    into    the   bladder,    previously 


Fig.  z$. — Indirect  catheterization.      Catheter  inserted  into  left  ureter. 

emptied  by  use  of  a  catheter.  The  obturator  being  withdrawn, 
any  remaining  urine  is  removed  from  the  bladder  with  an 
aspirator  especially  adapted  to  the  purpose.  The  light  is 
turned  on,  the  bevel  window  attached  and  the  bladder  is  in- 
flated with  air.  The  orifices  of  the  ureters  are  sought  for  and 
catheterized.  The  window  is  removed  and  the  air  allowed 
to  escape  from  the  bladder.     The  cystoscope  is  removed,  the 


58 


CYSTOSCOPY    AND    URETHROSCOPY 


catheters  being  threaded  in  at  the  same  rate  as  the  removal  of 
the  instrument. 


Fig.  34. — Ureteral  catheterization  (indirect  method).  Beak  of  cystoscope  pointing 
downward  in  bladder  (see  also  Fig.  29);  insertion  of  catheter  into  left  orifice  with 
right  hand. 


The   Pawlik-Kelly  Method. — Cystoscopy   is   employed   as 
described  for  this  method  in  a  previous  chapter.     The  orifice 


URETERAL    CATHETERIZATION 


59 


of  one  ureter  is  located  and  a  metal  catheter,  or  a  woven-silk 
catheter  armed  with  a  stylet  is  inserted  through  the  open  tube 


Fig.  35. — Withdrawal  of  cystoscope,  leaving  the  catheters  to  drain  the  ureters: 
the  sheath  is  being  steadied  by  an  assistant.  The  telescope  is  first  withdrawn  by  the 
left  hand,  while  the  catheters  are  fed  in  by  the  right.     Patient  comfortable. 

the  desired  distance  into  the  ureter.  The  same  procedure  is 
employed  for  the  other  ureter.  The  tube  is  now  withdrawn 
and  the  catheters  are  allowed  to  drain. 


6o  CYSTOSCOPY   AND    URETHROSCOPY 

The  simplicity  of  this  method  is  appeah'ng  but  it  is  open  to 
the  objections  of  necessary  previous  urethral  dilatation,  a  dis- 
agreeable posture  and  more  trauma  and  pain.  While  it  is 
ordinarily  only  applicable  in  the  female,  Luys  has  employed  a 
similar  procedure  in  the  male.  We  have  used  the  short  anterior 
tube  of  our  aero-urethroscope  for  catheterization  of  the  ureters 
in  the  female.  It  can  be  utilized  as  in  the  Pawlik-Kelly  method 
or  with  forced  air-inflation.  We  have  added  to  the  usual  ure- 
throscopic  accessories  a  catheter  carrying  tube  (Fig.  8i,F),  which 
may  be  employed  through  the  operating  window. 

Difficulties. — Of  the  causes  operative  against  successful 
catheterization  of  the  ureters,  insufficient  obtunding  of  sensa- 
tion is  the  most  common.  Insufficient  distention  of  the  bladder, 
lack  of  space  for  manipulation  in  greatly  contracted  bladders, 
profuse  hematuria,  new-growths  of  the  bladder,  obstruction  of 
the  ureteral  lumen  due  to  stone,  stricture,  kinking  or  extra- 
ureteral  pressure  and  malposition  of  the  ureteral  orifices  are  all 
factors  which  may  present  themselves  as  opposed  to  catheteri- 
zation. It  must  not  be  forgotten  that  in  bladders  which  are 
comparatively  normal,  the  interureteric  fold  and  the  ureteral 
eminences  may  not  be  observed.  In  very  anemic  cases  the 
intensity  of  the  coloring  which  characterizes  the  trigonum  may 
be  so  reduced  as  to  make  the  recognition  of  this  area  ex- 
tremely difficult.  Conversely,  in  a  bladder  which  has  been  the 
seat  of  pronounced  cystitis,  the  mucosa  may  be  of  a  uniform 
red  color  throughout  the  bladder,  thus  making  the  differentia- 
tion of  the  trigonal  area  from  the  surrounding  mucosa  difficult, 
if  not  impossible.  Only  the  practised  cystoscopist  will  be  able 
to  surmount  these  difficulties  and  this  ability  results  only 
from  long  and  painstaking  experience. 

The  correct  interpretation  of  the  findings  obtained  by 
ureteral  catheterization  is  of  extreme  importance.  Even  where 
the  utmost  care  has  been  observed  to  avoid  trauma,  blood  cells 
are  almost  constantly  found  under  the  microscope.  The  total 
urinary  picture  must  be  the  basis  for  diagnosis. 


URETERAL    CATHETERIZATION 


6i 


Occasionally,  the  urine  obtained  through  the  catheter,  though 
at  first  clear,  becomes  suddenly  macroscopically  bloody.   Casper 


Fig.  36. — Cystoscope  sheath  is  being  withdrawn  by  one  hand,  while  catheters  are  being 
fed  in  by  the  other — while  maintaining  their  same  relative  position  in  the    ureters. 

suggests  that  if  this  is  due  to  trauma  produced  by  the  catheteri- 
zation, that  the  catheter  should  be  pushed  farther  up  into  the  ure- 
ter.    We  are  of  the  opinion  that  the  hematuria  of  this  character 


62 


CYSTOSCOPY   AND    URETHROSCOPY 


is  due  to  a  congestion  of  the  ureteral  mucosa  dependent  upon 
the  presence  of  the  catheter  and  the  peristaltic  contractions 


Fig.  37. —  Cystoscope   withdrawn,   catheters   draining  into  rubber-capped   sterile  test 
tubes  (marked  R  and  L  as  shown  in  Fig.  38). 

of  the  ureter.  Where  the  cystoscope  is  removed,  leaving  the 
catheters  in  situ,  the  procedure  suggested  by  Casper  cannot  be 
carried  out. 


URETERAL    CATHETERIZATION  63 

Dangers. — The  dangers  of  infection  and  traumatism  which 
have  been  urged  against  catheterization  can,  we  believe,  be 
discussed  in  a  very  few  words.  Albarran,  Casper,  Kiimmel 
and  Landau,  whose  experience  is  based  upon  several  thousand 
cases,  are  unanimous  in  saying  that  these  supposed  dangers 
do  not  exist.  In  our  experience,  which  has  been  fairly  extensive, 
we  have  never  encountered  a  case  of  infection  arising  from 
this  procedure.  With  sterile  instruments  and  careful  atten- 
tion to  technique,  we  may  dismiss  these  objections  as  having 
no  existence  in  fact. 

Kidney  Fimctionation. — In  the  diagnosis  of  relative  kidney 
functionation,  catheterization  of  the  ureters  plays  an  important 
part.  It  is  not  sufficient  to  know  that  a  supposedly  healthy 
kidney  is  secreting  a  normal  amount  of  urine.  The  ability  of 
each  kidney  as  an  excretory  organ  must  be  determined.  The 
nitrogen  output  of  each  kidney  varies  greatly  at  different  times 
and  it  is  necessary  to  have  the  total  excretion  for  a  period  of 
twenty-four  hours  or  longer,  in  order  that  the  excretory  ability 
may  be  determined.  As  it  is  both  inadvisable  and  impracticable 
to  leave  the  ureteral  catheters  in  place  for  so  long  a  time,  differ- 
ent methods  for  a  rapid  determination  of  the  functional  activity 
of  each  kidney  have  been  devised.  We  have  at  our  disposal 
four  distinct  methods:  Chromocystoscopy,  the  Phloridzin  Test, 
Urinocryoscopy  and  Hemocryoscopy,  and  the  Phenolsulphone- 
phthalein  Test. 

Chromocystoscopy. — In  1853,  Beauvaire  remarked  the  ab- 
sence of  the  characteristic  odor  of  asparagus,  after  its  ingestion, 
from  the  urine  of  nephritic  patients.  It  is  upon  this  selective 
elimination  of  certain  substances  by  the  healthy  kidneys,  that 
both  Chromocystoscopy  and  the  Phloridzin  Test  are  based. 

As  indicated  by  the  term  "Chromocystoscopy,"  this  test 
depends  upon  the  ability  of  the  kidneys  to  eliminate  certain 
dyes.  Methylene-blue  and  indigo-carmine  have  been  made 
use  of  for  this  purpose.  If  methylene-blue  be  administered  in 
a  normal  dosage,  the  characteristic  greenish-blue  tinge  may  be 


64  CYSTOSCOPY   AND    URETHROSCOPY 

noted  in  the  urine  excreted  by  a  healthy  kidney  in  from  fifteen 
to  thirty  minutes  after  ingestion.  Any  pronounced  delay  in 
the  elimination  of  this  drug  is  considered  to  be  very  suggestive 
of  crippled  functionation.  Ackard  and  Castaigne  believe  that 
a  delay  of  one  hour  or  longer,  indicates  pronounced  disease. 
Further  investigation  by  Walker  and  others  has  proved  these 
findings  to  be  fallacious,  so  that  no  dependence  can  be  placed 
upon  the  elimination  of  methylene-blue  as  an  accurate  test  of 
kidney  functionation.  In  pronouncedly  alkaline  urine,  no 
coloring  is  to  be  observed.  The  methylene-blue  may  be  ad- 
ministered hypodermically,  about  twenty  to  thirty  minims  of  a 
I  per  cent,  solution  being  used. 

The  use  of  indigo-carmine  seems  to  be  more  dependable. 
Following  the  injection  into  the  gluteal  muscles  of  sixteen  centi- 
grams of  indigo-carmine,  Velcher  and  Joseph  have  observed 
the  elimination  of  purple-tinted  urine  from  normal  kidneys  in 
from  fifteen  to  thirty  minutes.  Any  marked  diminution  in  color 
is  held  to  be  due  to  disabled  kidney  functionation.  The  pub- 
lished results  of  different  investigators  bear  out  this  contention. 

By  filling  the  bladder  with  a  dilute  solution  of  hydrogen 
peroxide  to  which  starch  has  been  added  and  by  the  internal 
administration  of  iodide  of  potassium,  the  same  authors  (Velcher 
and  Joseph)  have  observed  the  bluish  discoloration  which  takes 
place  when  the  urine  ejected  from  the  ureters  comes  into  contact 
with  the  starch  solution.  The  diminution  in  color  reaction  is 
said  to  be  diagnostic  but  the  reliability  of  the  test  has  not  been 
very  strongly  urged. 

The  Phloridzin  Test.^While  Von  Mehring  first  established 
the  fact  that  the  administration  of  phloridzin  is  followed  by  a 
glycosuria  without  a  hyperglykemia,  Klemperer  was  the  first 
to  study  the  elimination  of  sugar  in  phloridzin-glycosuria  in  its 
relation  to  kidney  functionation.  In  Klemperer's  experiments 
the  phloridzin  was  administered  by  the  mouth  and  he  found,  as 
the  result  of  his  investigations,  that  glycosuria  did  not  occur  in 
contracted  kidney.     Magnus  Levy,  in  subsequent  experimenta- 


UEETERAL    CATHETERIZATION 


65 


tion,  proved  that  phloridzin,  if  ingested,  was  subject  to  such 
chemical  change  as  to  nullify  the  conclusions  of  Klemperer.     He 


Fig.  38. — Lavage  of  left  kidney  pel\-is.  Drainage  having  been  completed,  medicated 
solution  is  being  injected  through  the  corresponding  catheter.  Ureteral  syringe  fits 
over  the  end  of  the  catheter. 

obtained  a  glycosuria  following  the  hypodermic  administration 
of  phloridzin  in  granular  atrophy  and  other  pathologic  conditions 

5 


66  CYSTOSCOPY   AND   URETHROSCOPY 

of  the  kidney.  Following  other  French  investigators,  Casper 
and  Richte'r  undertook  an  exhaustive  study  of  phloridzin- 
glycosuria  in  its  relation  to  kidney  functionation.  They  found 
the  relative  elimination  of  sugar  by  each  kidney  to  be  of  excep- 
tional value  in  determining  functional  activity.  The  work  of 
Krotoszyner,  of  San  Francisco,  has  been  of  much  value  in  estab- 
lishing the  reliability  of  this  procedure. 

From  fifteen  to  twenty-five  minims  of  a  ^  to  a  4  per 
cent,  solution  is  injected  hypodermically.  The  solution  must 
be  fresh  and  warm.  Krotoszyner  insists  upon  the  impor- 
tance of  these  points  and  traces  certain  failures  in  the  work  of 
other  investigators  to  old  or  cold  solutions.  Elimination  begins, 
as  a  rule,  thirty  minutes  after  injection  and  is  at  its  height  about 
one  hour  after  injection.  Larger  dosage  has  a  tendency  to 
decrease  the  time  elapsing  between  the  injection  and  the  begin- 
ning of  elimination. 

While  the  Phloridzin  Test  is  of  unquestioned  value,  it  must 
not  be  forgotten  that  the  discrepancy  between  the  amounts  of 
sugar  eliminated  by  the  two  kidneys  must  be  greatly  marked 
before  any  reliance  can  be  placed  upon  its  diagnostic  value.  An 
absence  of  sugar  from  both  urines  would,  of  course,  establish  the 
fact  of  crippled  functionation  in  both  kidneys. 

Cryoscopy. — While  cry oscopy  was  first  suggested  by  DeCoppet 
in  187 1  and  extensively  investigated  by  Raoult,  who  published 
the  results  of  his  researches  in  1882,  it  was  not  until  1898  that 
Koranyi  employed  this  physiochemic  procedure  to  determine 
the  clinical  significance  of  the  difference  in  the  osmotic  pressure 
of  the  urine  and  the  blood.  This  work  was  later  taken  up  by 
Senator,  Klimmel,  Casper  and  Richter,  Albarran,  Tieken  and 
others. 

To  take  up  in  detail  the  physiochemic  explanation  of  this  pro- 
cedure and  the  exhaustive  studies  of  those  who  have  developed 
cryoscopy,  is  beyond  the  purpose  of  this  work.  It  suffices  to 
say  that  cryoscopy  is  based  upon  the  fact  that  the  more  concen- 
trated the  solution,  the  lower  is  the  freezing  point.     The  freezing 


URETERAL    CATHETERIZATION  67 

point  of  normal  urine  varies  from  —1.2°  to  —2.3°  centigrade 
(Lindemann).  When  the  molecular  concentration  diminishes 
to  the  point  that  the  freezing  point  is  raised  above  —0.9° 
centigrade,  it  is  indicative  of  renal  insufhciency. 

Urinocryoscopy  is  of  little  value  unless  the  freezing  points  of 
the  two  urines  obtained  by  ureteral  catheterization  and  the 
freezing  point  of  the  blood  are  taken  into  consideration  as  the 
basis  for  diagnostic  and  prognostic  reasoning. 

The  normal  freezing  point  of  the  blood  is  considered  to  be 
—  0.56  centigrade  (Dreser). 

With  renal  insufhciency  there  is  a  retention  of  waste  products 
in  the  blood  and  a  consequent  lowering  of  its  freezing  point. 

Lindemann  has  pointed  out  that  so  long  as  the  pathological 
involvement  is  limited  to  the  pelvis  of  the  kidney,  no  deviation 
from  the  normal  freezing  point  is  noticed.  This  deviation  only 
occurs  when  the  disease  involves  the  kidney  parenchyma. 

The  fact  that  in  the  use  of  cryoscopy  a  most  expert  knowledge 
of  physics  and  chemistry  is  absolutely  requisite  for  the  observ- 
ance of  the  essential  technique  and  that  even  under  the  strictest 
technique  sources  of  error  may  creep  in,  must  necessarily  limit 
the  field  of  usefulness  of  this  procedure.  Carried  out  under 
painstaking  technique  and  in  the  hands  of  a  competent  physicist 
it  is  of  undoubted  value,  but  even  Rumpel,  Kiimmel's  most 
enthusiastic  assistant,  suggests  that  its  use  should  be  combined 
with  Chromocystoscopy,  and  the  Phloridzin  Test  in  order  that 
accurate  deductions  may  be  made. 

In  connection  with  cryoscopy,  the  electrical  conductivity  of 
the  urine  has  been  utilized  as  a  test  of  functionation.  This 
method,  however,  has  not  been  developed  to  the  degree  that  we 
are  justified  in  drawing  conclusions  as  to  its  value  in  determining 
kidney  functionation. 

THE  PHENOLSULPHONEPHTHALEIN  TEST 

This  test  which  has  been  put  upon  a  thoroughly  definite  basis 
through  the  studies  of  Geraghty  and  Rowntree,  is,  in  the  opinion 


68  CYSTOSCOPY   AND    URETHROSCOPY 

of  those  who  have  used  the  method  extensively,  the  most  depend- 
able of  all  tests  for  determining  renal  functionation.  The  tech- 
nique is  relatively  simple.  As  given  by  its  authors  in  a  com- 
munication read  before  the  New  York  Academy  of  Medicine  it 
is  as  follows: 

"Twenty  minutes  to  half  an  hour  before  administering  the 
test,  the  patient  is  given  300  to  400  cubic  centimeters  of  water  in 
order  to  insure  free  urinary  secretion,  otherwise  delayed  time 
of  appearance  may  be  due  to  lack  of  secretion. 

"Under  aseptic  precautions  a  catheter  is  introduced  into  the 
bladder,  and  the  bladder  completely  emptied.  Noting  the  time, 
one  cubic  centimeter  of  a  carefully  prepared  solution  of  the 
phenol  sulphonephthalein  containing  six  miUigrams  to  the  cubic 
centimeter  is  accurately  administered  subcutaneously,  intra- 
muscularly or  intravenously  by  means  of  an  accurately  gradu- 
ated syringe.  (We  have  used  a  two  cubic  centimeter  syringe, 
which  is  graduated  in  fifths  of  a  cubic  centimeter.) 

"The  urine  is  allowed  to  drain  into  a  test-tube  in  which  has 
been  placed  a  drop  of  25  per  cent,  sodium  hydroxid  solution,  and 
the  time  of  the  appearance  of  the  first  faint  pinkish  tinge  is 
noted. 

"In  patients  with  urinary  obstruction,  the  catheter  is  with- 
drawn at  the  time  of  the  appearance  of  the  drug  in  the  urine, 
and  the  patient  is  instructed  to  void  into  a  receptacle  at  the  end  of 
one  hour,  and  into  a  second  receptacle  at  the  end  of  the  second 
hour. 

"A  rough  estimate  at  the  time  of  appearance  can  be  made 
by  having  the  patient  void  urine  at  frequent  intervals,  without 
the  use  of  the  catheter.  In  prostate  cases  it  is  wise  to  have  the 
catheter  in  place  until  the  end  of  the  observation. 

"When  a  catheter  is  to  be  employed,  it  is  well,  previously, 
to  have  the  patient  under  the  influence  of  hexamethylenamin. 

"Sufficient  sodium  hydroxid  (25  per  cent,  is  added)  to  make 
the  urine  decidedly  alkaline  in  order  to  elicit  the  maximum 
color.     The  color  displayed  in  the  acid  urine  is  yellow  or  orange, 


URETERAL    CATHETERIZATION  69 

and  this  immediately  gives  place  to  a  brilliant  purple-red  color 
when  the  solution  becomes  alkaline.  This  solution  is  now  placed 
in  a  liter  measuring-flask  and  distilled  water  added  to  make 
accurately  one  liter.  The  solution  is  then  thoroughly  mixed, 
and  a  small  filtered  portion  taken  to  compare  with  the  standard 
which  is  used  for  all  of  these  estimations. 

"Recently  the  Hellige  hemoglobinometer,  especially  modified 
for  use  in  connection  with  the  phthalein  work,  has  been  utilized. 
A  standard  alkaline  solution,  six  grams  to  a  liter,  is  placed  in  the 
wedge-shaped  cup.  The  urine  collected  is  diluted  to  a  liter  and 
a  small  filtered  portion  poured  into  the  rectangular  cup.  The 
wedge-shaped  cup  is  now  manipulated  by  means  of  the  screw 
until  the  two  sides  of  the  color  field  are  identical.  The  percent- 
age on  the  scale  is  now  noted.  This  instrument  is  much  cheaper 
than  the  Duboscq  and  approximately  accurate.  Fairly  accurate 
estimations,  however,  can  be  obtained  by  means  of  graduated 
cylinders — equal  quantities  of  the  standard  solution  and  of  the 
diluted  urine  being  used  in  separate  cylinders,  and  the  denser 
solution  being  diluted  until  the  colors  become  identical.  The 
amount  of  the  drug  in  the  solution  being  known,  the  amount  in 
the  urine  can  be  readily  calculated. 

"When  the  collected  urine  has  been  made  strongly  alkaline,  it 
is  necessary  to  estimate  the  phthalein  within  a  few  hours,  as  the 
red  color  fades  gradually  under  these  conditions.  When  it  is 
desirable  or  necessary  to  defer  the  estimation  for  some  hours  or 
days,  it  is  better  to  make  the  urine  distinctly  acid,  under  which 
condition  the  phthalein  remains  unchanged.  It  should,  of 
course,  be  made  alkaline  again  when  the  estimation  is  made. 

"Excretion  in  Normal  Individuals. — The  excretion  has  been 
studied  in  several  hundred  normal  individuals.  In  our  earlier 
work  subcutaneous  administration  was  used  exclusively,  the 
drug  appearing  in  the  urine  in  from  five  to  eleven  minutes,  38  to 
60  per  cent,  (average  50  per  cent.)  being  excreted  in  the  first  hour 
after  its  appearance  in  the  urine,  and  60  to  85  per  cent,  for  two 
hours.     In  health  the  elimination  is  practically  complete  in  two 


yo  CYSTOSCOPY   AND   URETHROSCOPY 

hours,  only  a  trace  being  present  during  the  third  and  fourth 
hours. 

"Recently  intramuscular  and  intravenous  injections  have  been 
employed.  The  time  of  appearance  following  the  intramuscular 
administration  is  practically  the  same  as  that  after  the  sub- 
cutaneous, but  the  output  averages  5  to  lo  per  cent,  more  for 
the  first  hour.  Following  the  intravenous  injection,  the  drug 
normally  appears  in  from  three  to  five  minutes,  and  from  35  to 
45  per  cent,  of  the  drug  is  eliminated  in  the  first  fifteen  minutes, 
50  to  65  per  cent,  in  the  first  half  hour  and  63  to  80  per  cent,  dur- 
ing the  first  hour.  This  rapidity  of  the  excretion,  following  the 
intravenous  administration,  is  exceedingly  striking,  and  when 
this  method  is  employed,  observations  for  a  quarter  hour  or 
half  hour  period  only  should  be  employed.  For  general  use, 
however,  we  advocate  the  lumbar  intramuscular  method  (the 
latter  particularly  when  the  edema  is  present),  as  the  technique 
involved  is  much  simpler  and  the  results  obtained  are  reliable. 
The  technique  of  the  test  is  exceedingly  simple.  The  injection 
is  given,  time  of  appearance  noted,  and  collection  of  urine  made 
for  one  or  two  hours.  To  each  sample  sufficient  sodium  hydrate 
is  added  to  insure  alkalinity  and  maximum  intensity  of  color; 
then  the  urine  is  diluted  to  one  Hter,  a  small  amount  is  filtered, 
the  reading  made,  and  the  percentage  of  the  drug  excreted  is 
calculated."* 

*  Jour.  A.  M.  A.,  Sept.  2,  1911,  Vol.  LVII,  pp.  811-816.. 


CHAPTER  V 
URETERO-PYELOGRAPHY* 

Attempts  to  render  the  urinary  tract  opaque  to  the  X-ray 
through  the  injection  of  various  media  have  been  made  repeat- 
edly in  the  past  decade.  The  different  substances  used  include 
lime  water,  bismuth,  collargol  (Voelcker  and  Lichtenberg^), 
argyrol  (Keyes-),  cargentos  (Uhle'^),  air  and  oxygen  (Lich- 
tenberg  and  Dietlen"^).  To  Voelcker  and  Lichtenberg  must 
be  given  the  credit  of  first  demonstrating  a  radiogram  of  an 
injected  renal  pelvis  in  the  living.  Subsequent  investigators 
have  demonstrated  that  the  radiogram  following  injection  is  of 
considerable  practical  aid  in  the  diagnosis  of  numerous  con- 
ditions in  the  urinary  tract. 

Technique. — Of  the  various  media  injected,  colloidal  silver 
seems  to  be  the  most  satisfactory.  That  medium  which  can  be 
used  in  the  weakest  solution,  casts  the  clearest  shadow,  and  is 
the  least  irritating,  should  be  the  one  of  choice.  Colloidal 
silver,  which  at  present  seems  to  fulfil  these  requirements  best, 
when  used  in  a  lo  per  cent,  aqueous  solution,  will  outline  the 
ureter  and  renal  pelvis  quite  definitely.  The  following  technical 
precautions  should  be  observed:  (i)  The  colloidal  silver  crystals^ 
should  be  ground  in  a  mortar  when  put  in  solution  and  then  fil- 
tered in  order  that  undissolved  crystals  may  not  be  deposited 
in  the  renal  pelvis  and  cause  irritation.  A  solution  too  thick  to 
easily  pass  through  a  fine  needle  should  not  be  used.  (2)  The 
solution  should  be  carefully  warmed  just  before  using  and  not 
boiled.  (3)  As  a  routine  procedure,  injection  of  the  solution  by 
gravity*^  is  preferable  in  order  to  obviate  over-distention.  (4) 
Unless  evidence  of  ureteral  obstruction  is  at  hand  from  two  to 

*  Written  by  William  F.  Braasch,  Mayo  Clinic,  Rochester,  Minn. 

71 


72 


CYSTOSCOPY    AND    URETHROSCOPY 


eight  cubic  centimeters  of  the  solution  will  suffice  to  outline  the 
pelvis.  Care  must  be  taken  not  to  inject  the  medium  too  rapidly 
because  of  the  possibility   of   over-distending  the  pelvis  and 


Pjc^  39.— Irregular,  tortuous  outline  of  the  right  ureter  caused  by  the  blood  clot  filling 
the  pelvis  and  upper  ureter.     Normal  pelvis  and  ureter  on  the  left  side. 

causing  renal  colic.  A  short  radiographic  exposure  is  preferable 
because  respiratory  movement  and  slight  change  of  position 
may  render  the  pelvic  outline  indistinct. 


URETERO-PYELOGRAPHY 


73 


Fig.  40. — Irregular  inflammatory  dilatation  of  the  pelvis  of  the  kidney  caused  by  a 
bleeding  pyelitis.     Upper  ureter  involved  as  far  as  the  first  point  of  narrowing. 


74 


CYSTOSCOPY   AND    URETHROSCOPY 


Excluding  possible  errors  in  radiographic  technique,  failure 
in  obtaining  a  satisfactory  radiogram  may  be  due  to  any  of  the 


Fig.  41.— Dilatation  of  right  ureter  caused  by  stone  lodged  in  that  part  of  the  ureter 
where  it  enters  the  wall  of  the  bladder. 

following    conditions:  (i)  Old    and    weakened    solutions;    (2) 
return  of  injected  solutions  because  of  an  occluding  ureteral 


URETERO-PYELOGRAPHY  75 

obstruction;  (3)  obliteration  of  the  pelvis  by  tumor,  stone  or 
inflammatory  changes;  (4)  dilution  of  the  injected  solution  by 
retained  fluids;  (5)  immediate  colic  following  over-distention 
of  the  pelvis. 

The  Normal  Pelvis. — The  outline  of  the  normal  pelvis  will 
vary  greatly  depending  on  the  number,  depth,  breadth  and  con- 
tour of  its  calices  as  well  as  the  extent  to  which  the  free  wall 
distends.  In  order  to  correctly  interpret  actual  abnormality 
one  should  first  become  familiar  with  this  wide  range  of  normal 
pelvic  contour.  The  variation  from  the  normal  outline  must 
be  marked  in  order  to  recognize  it  as  pathologic.  The  pelvis 
should  not  be  over-distended  while  being  radiographed,  other- 
wise the  resulting  contraction  of  the  pelvic  wall  may  leave  but 
a  narrow  irregular  slit.  On  the  other  hand  in  order  to  demon- 
strate pelvic  deformity  of  moderate  degree  the  pelvis  should 
be  well  filled.  Should  the  kidney  move  while  the  radiogram  is 
being  made,  the  outline  may  become  blurred  and  appear  abnor- 
mally large.  Evident  detachment  of  calices  is  a  peculiarity 
which  may  occasionally  be  found  confusing.  It  is  best  there- 
fore to  make  several  successive  pyelograms  with  slightly  in- 
creasing pelvic  distention  in  order  to  obtain  an  accurate  pelvic 
outline. 

Hydronephrosis. — Distention  of  the  renal  pelvis  as  the  result 
of  ureteral  obstruction  can  be  clearly  demonstrated  in  the  pyelo- 
gram  providing  a  sufficient  amount  of  the  injected  medium 
reaches  the  pelvis.  The  dilatation  will  be  readily  recognized  by 
the  increased  size  of  the  pelvic  lumen  as  well  as  by  the  broad, 
knobbed  shape  of  the  calices  ("Derby  hat" — Keyes).  The 
greater  the  distention  the  shallower  and  broader  will  the  calices 
appear.  In  extreme  cases  they  may  be  completely  effaced  from 
the  pelvic  outline  and  but  a  rim  of  cortex  remain.  Occasionally 
the  free  pelvic  wall  may  be  prevented  from  much  distention 
because  of  peri-pelvic  inflammatory  changes  and  the  distention 
may  be  confined  within  the  border  of  the  kidney.  As  a  result  the 
parenchyma  is  flattened  and  the  dilated  calices  will  be  the  diag- 


76 


CYSTOSCOPY   AND    URETHROSCOPY 


Fig.  42. — Beginning  small  hydronephrosis  showing  broadening  of  the  calices  of  the 
terminal  irregularities.  True  pelvis  small.  This  type  of  dilatation  is  typical  of  obstruc- 
tion in  the  lower  ureter.     Moderate  dilatation  of  the  ureter  visible. 


URETERO-PYELOGRAPHY  77 

nostic  features.  The  etiologic  factors  can  often  be  interpreted 
from  the  contour  of  the  distention.  The  mechanical  or  retention 
dilatation  is  distinguished  from  the  inflammatory  distention  by 
the  comparative  regularity  of  its  outline  as  seen  in  the  even  lines 
of  the  free  wall  and  rounded  ends  of  its  broad  calices.  Elon- 
gated or  pear-shaped  distentions  are  usually  due  to  constriction 
a  short  distance  below  the  uretero-pelvic  juncture,  very  often 
anomalous  renal  blood  vessels.  When  the  obstruction  exists 
in  the  lower  portion  of  the  ureter,  distention  of  the  individual 
calices  is  usually  proportionally  greater  than  that  of  the  free 
pelvic  wall.  The  ureter  may  be  markedly  distended  with  but 
moderate  dilatation  apparent  in  the  calices  and  little  or  none  in 
the  true  pelvis.  In  order  to  render  the  outline  distinct  with 
extensive  dilatation  it  may  be  necessary  first  to  drain  away  as 
much  of  the  retained  fluid  as  possible  before  injecting.  Pyelog- 
raphy is  of  particular  value  in  ascertaining  the  existence  and 
extent  of  early  hydronephrosis  (twenty  to  fifty  cubic  centi- 
meters). The  earliest  changes  consist  in  broadening  of  the  cali- 
ces and  flattening  of  the  fine  terminal  endings.  Not  infre-y 
quently,  however,  the  normal  pelvis  will  show  broadening  of 
several  calices  and  an  exceptionally  large  pelvic  outline  that  may 
be  difiicult  to  differentiate  from  the  changes  of  early  hydro- 
nephrosis. To  be  of  practical  value,  therefore,  the  pelvic  de- 
formity must  be  considerable. 

The  Inflammatory  Pelvic  Dilatation. — The  outline  of  the 
inflammatory  distention  is  characterized  by  its  marked  irregu- 
larity. The  degree  of  irregularity  will  vary  with  the  extent  of 
the  inflammatory  process.  Pyelitis  when  recent  and  of  moderate 
severity  will  show  but  slight  and  often  indistinguishable  changes. 
Chronic  pyelitis  with  scar  tissue  changes  in  the  pelvic  wall  may 
show  considerable  irregular  distention.  Pyelitis  resulting  from 
stones  within  the  pelvis  is  often  characterized  by  the  marked 
irregularity  of  individual  calices,  although  the  general  outline 
will  depend  largely  on  the  degree  of  mechanical  obstruction.  In 
cases  where  the  inflammatory  process  has  extended  into  the  peri- 


78 


CYSTOSCOPY   AND    URETHROSCOPY 


pelvic  tissues  we  frequently  find  the  upper  ureter  involved.  The 
resulting  dilatation  may  be  consequent  to  mechanical  obstruc- 
tion of  peri-pelvic  scar  tissue  changes  or  to  the  cicatricial  retrac- 
tion of  the  ureteral  wall  itself.     In  exceptional  cases  the  pelvic 


Fig.  43. — Outline  of  normal  pelvis  of  both  sides.  Note  terminal  irregularities  of 
minor  calices  which  prove  them  to  be  normal.  The  irregular  dim  shadows  adjacent 
to  the  right  pelvis  are  caused  by  gall-stones.  Their  extra-renal  situation  is  proved  by 
the  absence  of  inflammatory  changes  and  relation  to  the  calices. 


distention  may  show  the  characteristics  of  both  the  inflammatory 
and  mechanical  distention.  With  the  extensive  inflammatory 
changes  accompanying  pyonephrosis  the  irregular  wide  calices 
may  be  seen  extending  into  the  farthest  limits  of  the  cortex. 


URETERO-PYELOGRAPHY 


79 


Frequently  the  pelvis  will  be  seen  fringed  with  detached  shadows 
of  varying  size  which  are  caused  by  cortical  abscesses  connected 
with  the  pelvis. 


Fig.  44. — Dilated  ureter  and  pelvis  caused  by  stone  in  the  lower  ureter.  Note 
lateral  insertion  of  the  ureter.  Congenital  anomaly  occasionally  seen  in  association 
with  horseshoe  kidney  as  in  this  case. 

Tumor  Deformity. — On  account  of  the  wide  variation  in  size 
and  shape  of  the  normal  reno-pelvic  outline  the  tumor  must 


8o 


CYSTOSCOPY   AND    URETHROSCOPY 


show  considerable  deformity  in  order  to  interpret  it  as  abnor- 
mal. The  majority  of  renal  tumors  removed  at  operation  will 
show,  on  section,  considerable  abnormality  in  the  pelvic  contour. 
This  deformity  results  from  the  retraction  of  the  various  calices 


Fig.  45. — Colloidal  silver  outlining  right  ureter  rules  out  shadow  which  might  have 
been  interpreted  as  being  stone  in  the  ureter  if  the  stilet  alone  were  used. 

or  encroachment  into  the  pelvic  space  by  the  surrounding 
tumor  tissue.  In  case  of  tumor  retraction  the  following  ab- 
normalities may  be  demonstrated  in  the  radiogram  after 
injection:  (i)  Irregular  dilatation  of  the  entire  pelvis;  (2)  re- 


URETERO-PYELOGRAPHY  8l 

traction  or  distention  of  one  or  more  calices,  often  to  a  consider- 
able extent;  (3)  retraction  of  the  pelvis  and  upper  ureter  at  the 
uretero-pelvic  juncture.  In  case  of  tumor  encroachment  but 
very  Httle  of  the  pelvic  lumen  need  remain  in  order  to  identify 
actual  deformity.  Irregular  narrow  streaks  at  either  side  of  the 
protruding  tissue  may  outline  the  remaining  pelvic  spaces.  If 
the  pelvis  is  largely  obliterated  by  the  tumor  the  small  amount 
of  colloidal  silver  that  enters  the  remaining  pelvic  lumen  is 
often  obscured  by  the  shadow  of  the  tumor  tissue  itself,  and 
only  the  adjacent  catheter  or  ureteral  shadow  may  be  visible 
in  the  radiogram  following  injection.  With  marked  retraction 
of  the  individual  calices  bizarre  shapes  of  the  pelvic  space  are 
frequently  seen.  In  such  cases  the  injected  medium  occasion- 
ally may  not  drain  away  readily,  as  the  remaining  shadows 
will  demonstrate  in  a  radiogram  taken  several  days  after  in- 
jection. Another  point  of  corroborative  value  in  suspected 
tumor  of  the  kidney  is  to  find  the  pelvis  situated  in  unusual  posi- 
tions such  as  over-lying  the  vertebral  column  or  laterally  dis- 
placed. With  necrosis  and  degeneration  of  the  tumor  tissue 
the  pelvic  outline  may  become  very  irregular,  even  resembling 
that  of  a  purely  inflammatory  process.  However,  it  will  not 
be  possible  to  make  a  radiographic  demonstration  of  distinct  pel- 
vic deformity  in  every  renal  neoplasm.  A  large  number  will 
not  have  enough  deformity  to  be  of  diagnostic  value.  Further- 
more, because  of  obstruction  to  the  ureteral  catheter  from 
various  abnormalities  in  the  course  of  the  ureter,  external  pres- 
sure or  even  ureteric  metastasis,  it  will  often  be  found  impossible 
to  reach  the  pelvis  with  the  injected  fluid. 

Organized  blood  clots  may  exist  in  the  pelvis  and  ureter 
even  though  the  urine  from  the  affected  kidney  appears  normal. 
A  pyelogram  made  of  a  pelvis  containing  these  clots  gives  a  pecu- 
liar outline  consisting  of  a  series  of  irregular  streaks  simulating 
marked  deformity  sometimes  observed  with  tumor. 

Tumor  Differentiation. — The  clinical  identification  of  tumors 
in  the  upper  lateral  abdomen  is  frequently  very  difficult.     Large 

6 


82  CYSTOSCOPY   AND   URETHROSCOPY 

tumors  of  the  peri-renal  organs  with  indefinite  symptoms  and 
clinical  findings  may  be  easily  confused  with  tumors  of  the  kid- 
ney. The  frequent  absence  of  any  urinary  symptoms  or  findings 
with  renal  neoplasms  leaves  us  no  localizing  data.  The  demon- 
stration of  pelvic  deformity  in  the  radiogram  following  injection 
would  identify  the  tumor,  while  the  absence  of  any  evident 
abnormality  would  in  most  instances  exclude  its  renal  origin. 
Again,  if  the  radiogram  made  after  injection  locates  the  pelvis 
high  and  the  tumor  is  felt  well  below  the  costal  margin,  the  two 
could  hardly  be  adjacent.  Finally,  the  tumor- mass  itself  will 
frequently  cast  a  faint  diffuse  shadow  in  the  radiogram  and  if  at 
some  distance  from  the  injected  renal  pelvis  will  further  exclude 
its  renal  nature. 

The  Cystic  Kidney. — Pelvic  deformity  as  the  result  of 
changes  in  the  parenchyma  of  the  polycystic  kidney  may  fre- 
quently be  rendered  visible  in  the  radiogram  following  injection. 
As  a  result  of  the  usual  increase  in  extent  of  the  renal  parenchyma 
consequent  to  cystic  changes  the  pelvic  space  is  encroached  upon 
to  a  varying  degree.  In  contradistinction  to  the  retraction  of 
calices  occurring  with  renal  neoplasm  we  usually  find  marked 
shortening  or  complete  effacement  of  calices.  As  a  result  the 
pelvic  outline  will  often  appear  roughly  oval  in  the  pyelograph 
with  one  or  more  irregular  indentations  representing  former 
calices.  Occasionally,  however,  with  large  cystic  kidneys 
evident  retraction  of  the  general  pelvic  outline  may  be  seen. 
With  marked  secondary  infection  the  resulting  outline  may  as- 
sume the  characteristics  of  a  pyonephrosis.  The  cystic  degen- 
eration will  not  affect  the  pelvic  outline  enough  to  render  any 
abnormality  apparent  in  more  than  two-thirds  of  the  cases. 
If  the  renal  tumor  be  clinically  regarded  as  possibly  polycystic, 
it  is  well  to  make  a  bilateral  pyelogram  even  though  but  one 
kidney  can  be  felt  enlarged. 

Localization  of  Renal  Shadows. — While  it  is  true  that  with 
good  radiographic  technique  the  kidney-shadow  can  usually 
be  fairly  well  outlined,  nevertheless,  for  various  reasons,  in  the 


URETERO-PYELOGRAPHY  83 

course  of  routine  examinations  it  will  frequently  happen  that 
the  renal  outline  is  quite  indefinite  or  will  not  show  at  all. 
Furthermore,  a  distended  gall-bladder,  displacement,  enlarge- 
ment or  anomaly  of  the  liver,  abdominal  tumor,  a  large  fatty 
capsule,  etc.,  often  cause  a  shadow  to  appear  in  the  radiogram 
which  may  easily  be  mistaken  for  the  kidney- shadow.  While 
it  is  very  often  possible  approximately  to  localize  renal  stones 
in  the  shadow  of  the  kidney  if  well  defined,  it  can  usually  be 
done  more  accurately  with  the  aid  of  the  pyelogram.  A  small 
stone  deep  in  the  calyx  may,  in  the  original  radiogram,  appear 
to  be  in  the  cortex,  while  in  the  pyelogram  the  shadow  of  a  cortical 
stone  would  be  seen  in  the  pyelogram  separated  from  the  pelvic 
shadow  and  its  relative  position  in  the  parenchyma  quite  accu- 
rately ascertained.  Stones  within  the  pelvis  will  either  be  ob- 
scured entirely  by  the  colloidal  silver  shadow  or  show  faintly 
through  it,  depending  on  the  comparative  densit}^  It  is  true 
that  cortical  stones  just  beyond  a  calyx  may,  in  exceptional 
cases,  appear  to  be  continuous  with  the  calyx-shadow  and  in  it. 
Furthermore,  dilated  ends  of  calices  may  appear  detached  and 
may  simulate  cortical  stones.  Again,  a  stone  in  the  lateral 
renal  cortex  in  direct  line  with  the  pelvis  might  appear  to  be 
within  the  pelvic  shadow,  depending  on  the  comparative  density 
of  the  stone  and  pelvic  shadow.  Such  a  lateral  position  is, 
however,  rather  infrequent.  Another  possible  source  of  con- 
fusion may  arise  when  extrarenal  shadows  are  in  direct  line  with 
the  pelvis  and  may  appear  included  within  it.  Unless  there 
is  much  pelvic  distention  the  injected  solution  should  be  com- 
paratively weak  in  order  that  the  stone- shadow  may  remain 
visible  in  the  injected  pelvis.  The  relative  position  of  the 
shadow  may  be  rendered  more  certain  by  making  the  radio- 
gram at  various  angles  or  stereoscopic.  Pyelographic  localiza- 
tion of  a  renal  stone  several  centimeters  or  more  in  diameter 
and  easily  felt  at  operation,  would,  as  a  rule,  be  unnecessary  and 
may  even  be  contraindicated.     With  a  small  stone,  however, 


84  CYSTOSCOPY   AND    URETHROSCOPY 

data  which  would  previously  have  localized  the  stone  may  be  of 
considerable  aid  in  finding  it  at  operation. 

Identification  of  Intrarenal  Shadows. — Stones  within  the 
pelvis  will  cause  variable  degrees  of  distention  more  or  less 
irregular  in  outhne.  The  dilatation  may  be  due  either  to  ob- 
struction at  the  pelvic  outlet,  to  inflammatory  changes  within 
the  pelvis,  or  individual  calices.  Not  infrequently  the  pelvic 
outline  will  assume  the  characteristics  of  both  mechanical  and 
inflammatory  dilatation.  Small  stones  may  occasionally  not 
cause  enough  changes  in  the  pelvic  outline  to  be  recognized  as 
abnormal.  Occasionally  dilatation  of  but  a  single  calyx  results 
when  a  small  stone  obstructs  the  outlet  of  the  calyx.  Distention 
of  the  calices  or  pel  vie  wall  resulting  from  previous  inflammation 
may  be  apparent  even  though  no  pus  nor  blood  is  found  in  the 
urine.  Small  cortical  stones  may  exist  without  symptoms  or 
urinary  findings  and  may  not  affect  the  pelvic  outline.  Cortical 
stones  with  inflammatory  changes  and  necrosis  in  the  surround- 
ing tissue  will  cause  more  or  less  inflammatory  distention  of 
the  pelvis. 

Identification  of  Extrarenal  Shadows. — Although  extrarenal 
shadows  can  usually  be  identified  as  such  in  the  radiogram  it  is 
at  times  difficult  to  do  so.  The  relation  of  the  injected  renal 
pelvis  to  an  adjacent  shadow  is  often  an  aid  to  its  identification. 
Extrarenal  shadows  which  may  confuse  interpretation  in  the 
region  of  the  kidney  are  caused  by  a  variety  of  conditions; 
those  commonly  misinterpreted  are  calcareous  deposits  in  adja- 
cent glands  and  blood  vessels.  The  absence  of  inflammatory 
changes,  the  intervening  distance  between  the  shadows  and  the 
pelvic  outline,  and  peculiarities  in  relation  to  the  calices  if  near 
the  pelvis  will  usually  enable  us  to  identify  the  shadows  as  extra- 
renal. With  the  development  of  the  radiographic  technique 
gall-stone  shadows  are  being  found  more  frequently  and  must  be 
considered  in  the  interpretation  of  shadows  in  the  right  kidney 
region.  Peculiarities  in  the  character  of  gall-stone  shadow  and 
negative  cystoscopic  data  are  frequently  suggestive  of  its  iden- 


URETERO-PYELOGR.AJ'HY  85 

tity.  The  distance  between  the  gall-stone  shadow  and  the  in- 
jected renal  pelvis  should  usually  identify  the  former  as  extra- 
renal. When  the  gall-bladder  lies  low  and  overlaps  the  area  of 
the  kidney  the  gall-stone  shadow  may  appear  to  be  intrarenal. 
Peculiarities  in  its  relation  to  the  injected  pelvis  and  absence 
of  inflammatory  changes  within  the  pelvic  outline  should  suffice 
to  identify  its  extrarenal  position.  Stereoscopic  radiograms 
may,  in  favorable  cases,  be  of  some  practical  value  in  their 
differentiation. 

Renal  Tuberculosis. — Not  infrequently  a  unilateral  pyelitis 
is  associated  with  an  ulcerated  bladder  and  on  cystoscopic 
examination  will  simulate  a  tuberculous  infection.  On  the 
other  hand,  renal  tuberculosis  may  infect  the  bladder  but  little 
and  the  cystoscopic  data  may  be  suggestive  of  a  simple  pyelitis. 
When  the  tubercle  bacillus  cannot  be  found  after  repeated  micro- 
scopic examinations  of  the  urine  and  guinea-pig  inoculation  is 
neither  available  nor  practical,  the  pyelogram  may  be  of  consid- 
erable value  in  differential  diagnosis.  With  tuberculosis  the 
following  changes  may  be  noted  in  the  pyelogram :  (i)  Moderate 
inflammatory  irregularity  of  calices;  (2)  one  or  more  calices 
merging  with  the  outline  of  a  connecting  cortical  abscess;  (3) 
irregular  distention  of  the  entire  pelvis;  (4)  irregular  destruction 
of  pelvis  and  calices.  With  simple  pyelitis  the  pelvis  usually 
shows  but  moderate  inflammatory  changes.  Needless  to  say,  a 
pyelogram  should  be  made  only  when  the  question  arises 
whether  or  not  the  condition  is  surgical  and  not  when  the 
kidney  is  manifestly  destroyed  or  when  guinea-pig  inoculation 
is  available. 

Congenital  Malformations. — The  existence  of  various  con- 
genital anomalies  in  the  kidney  and  ureter  can  frequently  be 
definitely  determined  in  the  uretero-pyelogram.  The  position 
of  the  ectopic  or  pelvic  kidney  is  clearly  demonstrated  in  its 
relation  to  the  surrounding  bony  structure.  The  fused  kidney 
with  its  adjacent  pelves  and  converging  ureters  can  be  distinctly 
traced  to  its  exact  location.     When  the  lower  pelvis  of  a  fused 


86  CYSTOSCOPY   AND    URETHROSCOPY 

kidney  lies  over  the  sacrum,  the  resulting  pyelogram  might  eas- 
ily be  confused  with  that  accompanying  an  ectopic  kidney  and  an 
adjacent  normal  kidney.  As  a  rule,  however,  the  distance  sepa- 
rating the  two  pelvic  outlines  will  enable  us  to  differentiate 
between  the  two  conditions.  DupHcation  of  the  renal  pelvis  is 
readily  demonstrated  in  the  pyelogram.  It  may  be  either  appar- 
ent or  true  according  to  the  point  of  union  of  the  calices.  The 
individual  calices  may  be  so  large  and  so  situated  that  they 
resemble  separate  pelves,  particularly  so  if  the  calices  do  not 
unite  until  just  beyond  the  hilum.  When,  however,  there  are 
two  distinct  pelves  within  the  hilum  and  each  has  its  separate 
calices  and  ureter  the  condition  must  be  considered  as  an 
actual  duplication  of  the  pelvis  and  become  of  surgical  impor- 
tance. It  is  of  considerable  practical  value  to  determine  whether 
the  two  pelves  are  independent  or  continuous.  If  united,  the 
calyx  connecting  the  adjacent  pelves  can  usually  be  outlined. 
Evidence  of  failure  in  rotation  of  the  kidney  may  be  apparent 
from  peculiarities  in  insertion  of  the  ureter  and  situation  of  the 
renal  pelvis.  Lateral  instead  of  median  insertion  of  the  ureter 
is  suggestive  of  fused  kidney  and  the  position  of  the  other  kid- 
ney should  always  be  determined.  The  combined  use  of  the 
metal  impregnated  catheter  in  one  side  and  the  pyelogram  in  the 
other  may  occasionally  be  indicated.  Complete  duplication  of 
the  ureter  from  pelvis  to  bladder  is  easily  demonstrated  by  the 
impregnated  catheter;  partial  duplication  and  division  of  the 
ureter  is  frequently  better  outlined  by  the  ureterogram.  Since 
it  is  usually  the  surgical  complication  which  calls  our  attention 
to  the  congenital  anomaly  in  the  kidney  or  ureter,  the  pyelo- 
gram will  be  found  of  particular  value  in  determining  the  nature 
and  extent  of  the  complication. 

Author's  Three-Ureter  Case. — This  was  remarkable  in 
several  respects.  So  far  as  known,  it  was  the  first  in  which 
three  different  urines  were  drawn  from  one  living  individual; 
the  first  in  which  one  of  three  ureters  was  demonstrated  to  be 
the  unique  source  of  recurrent  gonorrhea;  and  the  first  in  which 


URETERO-PYELOGRAPHY 


87 


LEFT 
SIDE 


RIGHT 
SIDE 


Fig.  46. — Three-ureter  case  of  Author,  in  which  one  of  the  three  ureters  had  been 
for  five  years  the  source  of  recurrent  {gonorrheal  infection  of  the  lower  urinary 
tract 


CYSTOSCOPY   AND    URETHROSCOPY 


Fig.  47.— Post-mortem   specimen   probably   analogous   to   the  condition   shown  in 
Fig.  46  of  the  living  individual. 


URETERO-PYELOGRAPHY 


89 


such  a  condition  was  permanently  relieved  by  direct  ureteral 
antiseptic  irrigation. 

The  patient,  a  male,  aged  24  years,  was  referred  by  Dr.  J. 
L.  Crook,  of  Jackson,  Tenn.,  on  Feb.  3,  1906.  There  had  been 
many  recurrences  of  urethral  gonorrhea  since  1900,  notwith- 
standing the  approved  methods  of  treatment  for  that  condition 


Fig.  48. — Radiogram  of  case  of  duplicated  ureter  and  pelvis,  catheters  and  collargol  in 
place.     Case  of  Dr.  R.  C.  Bryan. 

that  had  been  administered  by  several  capable  physicians  dur- 
ing that  time. 

Cystoscopy    and    ureteral    catheterization,    together    with 
radiography,  developed  the  following: 

1.  That  three  ureters  were  present,  giving  urines  of  three 
different  specific  gravities  and  other  characteristics. 

2.  That  two  of  the  urines  gave  clear  healthy  urine,  while 


Qo  CYSTOSCOPY   AND    URETHROSCOPY 

the  third  (issuing  from  the  median  opening)  gave  purulent 
urine,  the  subject  of  pure  culture  gonococcus  infection  in 
abundance. 

3.  A  few  irrigations  of  this  ureter  with  argyrol  solution 
disinfected  it  completely,  permitting  the  patient  to  go  home 
shortly  afterward,  entirely  and  permanently  relieved.  Since 
then  he  has  married  and  become  the  father  of  children,  without 
ever  having  had  a  recurrence  of  the  infection  that  had  lasted 
for  five  years.* 

Three-ureter  case  of  Dr.  R.  C.  Bryan  (Fig.  48):  Female,  35 
years  of  age,  complained  of  bloody  urine.  Cystoscopy  showed 
three  ureteral  orifices,  two  on  the  right  side.  From  the  mesial 
one  bloody  urine  containing  tubercle  bacilH  issued.  Catheteri- 
zation, collargol  injection  and  x-ray  photography  gave  the  ac- 
companying excellent  result.  It  probably  indicated  two  ureters 
and  two  pelves  draining  the  one  tuberculous  right  kidney. 

Operation  was  not  accepted. 

Solitary  Kidney. — The  pelvic  outline  of  the  solitary  or 
asymmetrical  kidney  differs  from  the  normal  only  in  its  extra- 
ordinary size  which  is  commensurate  with  its  parenchyma.  In 
the  pyelogram  the  pelvis  will  appear  unusually  large,  but  with 
its  calices  and  papillae  normal  in  outhne.  With  an  acquired 
single  kidney,  on  the  other  hand,  although  its  parenchyma  may 
show  considerable  hypertrophy,  the  pelvis  may  either  appear 
normal  in  size  and  contour,  or  show  moderate  elongation  of  the 
pelvis  and  calices. 

Ureteral  Dilatation. — Ureteral  dilatation  may  result  from 
either  mechanical  obstruction  or  inflammatory  retraction.  The 
outline  of  the  dilated  ureter  can  usually  be  demonstrated  in  the 
radiogram  after  injection.  The  dilatation  may  vary  in  degree 
from  a  scarcely  recognizable  distention  to  sacculation  of  several 
inches  in  diameter.  The  ureterographic  demonstration  of  ure- 
teral dilatation  above  a  questionable  stone-shadow  is  more  accu- 
rate than  the  ureteral  stilet  or  impregnated  catheter  in  identify- 

*For  full  report  of  the  case,  see  Medical  Record,  Oct.  6,  1906. 


URETERO-PYELOGRAPHY  9I 

ing  ureteral  stone.  A  small  percentage  of  stones  in  the  ureter  of 
recent  origin  will  not  cause  sufficient  distention  above  to  be 
recognized  as  such  in  the  pyelogram.  However,  such  stones 
may  be  recognized  as  being  intraureteral  by  a  nodular  enlarge- 
ment of  the  ur  et  er  at  the  si  te  of  the  shadow  in  question .  Appr ox  i- 
mately  25  per  cent,  of  the  stones  in  the  ureter  (particularly 
when  in  the  bladder  segment)  will  so  occlude  the  ureteral  lumen 
as  to  prevent  the  injected  fluid  from  getting  by.  Stone  in  the 
kidney  and  upper  ureter  with  but  few  exceptions  will  cause 
inflammatory  changes  in  the  outline  of  the  pelvis  and  ureter 
below.  The  inflammatory  ureteral  dilatation  may  occasionally 
be  the  only  data  at  hand  to  identify  the  intrarenal  nature  of  a 
doubtful  shadow.  Cicatricial  constriction  of  the  ureter  follow- 
ing inflammation  or  trauma  frequently  causes  marked  mechan- 
ical distention  of  the  ureter  above  it.  Mechanical  dilatation  of 
the  ureter  is  usually  greater  in  extent  than  that  caused  by  inflam- 
matory changes  in  the  ureteral  wall.  With  low-lying  constric- 
tion we  may  find  considerable  dilatation  of  the  ureter  above  with 
but  little  change  in  the  outline  of  the  pelvis.  The  pelvis  will 
dilate  last.  The  first  pelvic  changes  to  be  noted  are  the  broaden- 
ing of  the  isthmus  and  flattening  of  the  terminal  irregularities  of 
the  individual  calices.  A  peculiarity  occasionally  noted  is  that 
with  low  ureteral  obstruction  the  first  part  of  the  ureter  may 
remain  undistended  with  pelvic  distention  above  and  ureteral 
dilatation  below  it.  The  dilatation  accompanying  inflammatory 
changes  in  the  ureter  may  be  general  or  localized.  With 
descending  infection  the  entire  ureter  is  usually  involved  uni- 
formly, whereas  with  ascending  infection  the  process  is  usually 
localized  to  a  short  distance  above  the  bladder.  Localized 
inflammatory  dilatation  may  be  the  result  of  a  peri-ureteral 
process  such  as  is  seen  in  the  upper  ureter  with  peri-pelvic  inflam- 
mation. Ureteral  dilatation  may  be  consequent  to  retraction 
from  surrounding  tumor  tissue,  as  may  be  seen  with  renal  neo- 
plasm involving  the  upper  ureter  or  with  retroperitoneal  growths 
along  the  course  of  the  ureter.     Physiologic  obstruction  to  the 


92  CYSTOSCOPY   AND   URETHROSCOPY 

ureteral  catheter,  such  as  is  caused  by  acute  angulation  in  the 
course  of  the  ureter  as  it  leaves  the  wall  of  the  bladder  or  by 
folds  of  a  flaccid  ureter  and  loose  ureteral  mesentery,  will  show 
no  ureteral  dilatation  above  it.  The  ureterogram  may  be  the 
only  method  with  which  such  a  condition  can  be  clinically  iden- 
tified. With  marked  ureteral  distention  one  should  first 
endeavor  to  drain  as  much  of  the  retained  fluid  as  is  possible 
before  injecting  the  colloidal  silver  solution.  Profuse  return 
flow  alongside  the  catheter  in  a  flaccid  ureter  may  give  the 
appearance  of  moderate  distention.  It  can  easily  be  differen- 
tiated, however,  since  the  broadening  caused  by  return  flow  is 
evident  only  in  areas  giving  an  irregular  outline  to  the  ureter. 
Occasionally  ureteral  dilatation,  particularly  when  ascending  or 
the  result  of  chronic  bladder  retention,  may  be  demonstrated  in 
the  radiogram  after  filling  the  bladder  with  colloidal  silver  solu- 
tion, and  then  placing  the  patient  in  the  Trendelenburg  position. 
Contraindications  to  Uretero -pyelography. — Although  ure- 
tero-pyelography,  like  cystoscopy,  is  not  to  be  used  as  a  routine 
procedure  in  abdominal  diagnosis,  there  is  no  objection  to  its 
correct  employment  whenever  a  doubtful  radiogram,  cysto- 
scopic  examination  or  abdominal  tumor  leaves  the  diagnosis 
uncertain.  In  a  series  of  over  looo  cases  where  uretero-pyelog- 
raphy  was  employed  the  author  has  noted  neither  fatality  nor 
any  permanent  injury  resulting.  While  occasionally  the  exami- 
nation may  cause  pain,  a  severe  reaction  is  usually  the  result  of 
error  in  technique  or  lack  of  care  in  the  selection  of  cases. 
Unless  the  procedure  is  strongly  indicated  the  markedly  hyper- 
sensitive individual  should  not,  as  a  rule,  be  subjected  to  uretero- 
pyelography .  Pyelography  is  distinctly  contraindicated  in  cases 
of  large  hydronephrosis  where  the  dilatation  can  usually  be 
determined  merely  by  ureteral  catheterization.  Cystoscopy 
and  the  ureteral  catheter  alone  will  usually  aid  the  interpreta- 
tion of  large  radiographic  shadows  sufficiently  to  identify  them. 
Previous  localization  of  large  stones  easily  felt  in  the  kidney  at 
operation  is  unnecessary.     Whenever  the  drainage  of  the  kidney 


URETERO-PYELOGR.APHY  93 

pelvis  is  impaired  it  should  be  injected  with  caution.     However, 

the  long  list  of  conditions  in  the  urinary  tract  which  would 

remain  undiagnosed  without  uretero-pyelography  justifies  its 

use. 

REFERENCES 

1.  Voelcker,  F.  and  von  Lichtenberg,  A.:  ''Pyelographie 
(Rontgenographie  des  Nierenbeckens  nach  KollargolfuUung)," 
Miinchen.  med.  Wchnschr.,  1906,  liii,  105. 

2.  Keyes,  E.  L.,  Jr.:  "Radiographic  Studies  of  the  Renal 
Pelvis   and   Ureter,"   Tr.   Am.    Urol.   Assn.,    1909,    19 10,  iii, 

351-357,  I  Pl- 

3.  Uhle,  A.  A.  and  Pfahler,  Geo.  E. :  "Combined  Cystoscopic 

and  Rontgenographie  Examination  of  the  Kidneys  and  Ureter/' 
Ann.  Surg.,  1910,  H,  546-551. 

4.  Von  Lichtenberg,  A.  and  Dietlen,  H.:  "Der  Darstellung 
des  Nierenbeckens  und  Ureters  inRontgenbile  nach  Sauerstoffiil- 
lung,"  Miinchen  med.  Wochnschr.,   1911,^11,1,1341-1342. 


CHAPTER  VI 
CYSTOSCOPY  OF  THE  DISEASED  BLADDER 

The  study  of  the  diseased  bladder  and  the  proper  interpreta- 
tion of  the  pathological  conditions  found  therein  by  cystoscopy 
must  be  based  on  a  thorough  knowledge  of  the  cystoscopic 
appearance  of  the  bladder  in  a  condition  of  health.  Acting  on 
the  supposition  of  such  knowledge  we  shall  endeavor  in  this 
chapter  to  describe  as  accurately  as  possible  the  lesions  and 
abnormalities  of  the  pathologic  bladder,  though  we  are  keenly 
aware  that  any  description,  no  matter  how  exhaustive  and  pains- 
taking, must  be  inadequate  as  compared  with  clinical  in- 
vestigation. 

Congestion. — Occasionally,  the  cystoscopist  will  observe  a 
fine  and  closely  woven  increase  in  vascularity  on  the  bladder 
wall.  This  congestion  is  the  precedent  stage  of  a  cystitis.  By 
preference,  these  congested  areas  are  located  in  the  immediate 
neighborhood  of  the  ureteral  orfices  or  on  the  posterior  wall. 
Infection  or  irritating  sand-like  particles  draining  down  from 
the  kidneys  will  explain  the  congested  areas  about  the  orifices 
of  the  ureters,  while  the  patch  observed  on  the  posterior  wall 
is  very  ingeniously  explained  by  Fenwick  in  his  consideration 
of  "Inoculation  Cystitis,"  i.e.,  that  the  patch  is  caused  by  the 
posterior  wall  coming  in  contact  with  the  infected  internal 
meatus  in  the  collapsed  or  empty  bladder.  We  have  observed 
this  congested  area  after  catheterization,  caused  apparently  by 
the  vigorous  contraction  of  the  bladder  wall  on  the  tip  of  the 
catheter. 

This  congestion  is  readily  made  out  and  is  seen  to  consist  of  a 
thickly- woven  net-work  of  very  fine  vessels.  There  is  no 
appreciable  loss  of  epithelial  luster.  If  this  precystitic  stage 
continues  to  the  point  of  infection  a  cystitis  supervenes. 

94 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  95 

Cystitis.  Acute  Cystitis. — While  an  acute  cystitis  is,  as  a 
rule,  a  contraindication  to  cystoscopy,  it  occasionally  becomes 
necessary  to  secure  ocular  observation  of  the  acutely  inflamed 
bladder.  This  inflammation  may  be  generalized,  though  as  a 
rule,  it  is  confined  to  the  trigonum  and  the  immediate  surround- 
ing area.  While  of  not  particularly  common  occurrence,  the 
cystitic  area  or  areas  may  be  localized  on  any  part  of  the  mucosa. 
Fenwick  has  noted  a  cystitis  which  involved  but  one-half  of  the 
bladder,  the  other  hemisphere  remaining  absolutely  free  from 
infection. 

The  infected  area  is  seen  to  be  a  uniform  turgescent  red.\ 
There  is  a  distinct  loss  of  the  epithelial  luster  noted  on  the  normal  \ 
mucosa.     The  elasticity  of  the  infected  area  is  greatly  impaired.  ' 
giving  rise  to  a  rugose  appearance.     The  infected  zone  is  bor- 
dered by  a  thickly  woven  net-work  of  fine  vessels,  which  lose 
their  individuality  as  they  merge  into  the  turgescent  zone  of 
infection.     Submucous  hemorrhages  are  often  noted,  and  these 
small  areas  of  extravasation  are  often  noticeable  some  time  after 
the  acute  inflammation  has  subsided.     A  filmy  veil  of  muco-pus 
may  be  observed  slightly  hazing  over  the   inflamed  mucosa. 
The  whole  picture  is  one  of  acute  inflammation. 

If  the  infected  area  is  noted  to  immediately  surround  or 
trail  away  from  one  or  both  ureteral  orifices,  the  infection  may  ' 
safely  be  considered  to  be  a  descending  one.  ' 

If  in  conjunction  with  a  trigonal  cystitis,  a  cystitic  patch  is 
noted  on  the  posterior  wall,  this  patch  may  be  explained  as  an 
''inoculation  cystitis"  (Fenwick,  vide  supra).  Such  localized 
patches  may  be  the  result  of  infection  from  contiguous  pelvic 
inflammation. 

Subacute  and  Chronic  Cystitis.^ — Chronic  cystitis  may  pre- 
sent in  varied  forms,  somewhat  dependent  upon  the  etiologic 
factor. 

In  the  subacute  form  where  epithelial  destruction  has  been 
extensive  there  is  an  almost  entire  loss  of  epithelial  luster,  so 
that  with  a  perfect  illuminating  power  in  the  cystoscope,  the 


96  CYSTOSCOPY   AND   URETHROSCOPY 

picture  may  appear  vague  and  blurred,  the  so-called  "light- 
absorbing"  bladder.  The  mucosa  is  a  uniform  dark  red. 
Rugosities  are  observed  with  great  regularity  and  the  bladder 
evinces  a  tendency  toward  stiffness,  i.e.,  loss  of  elasticity.  Here 
and  there  a  film  of  mucopus  is  seen  clingmg  to  the  mucosa. 
Sloughy  looking  white  patches  may  be  observed  attached  to  the 
dark-red  back  ground,  a  form  of  cystitis  to  which  the  terms 
"diphtheritic,"  "desquamative"  and  "membranous"  have  been 
applied.  In  the  severer  grades  of  vesical  inflammation,  large 
grayish  areas  of  sloughing  mucosa  may  be  noted. 

In  the  chronic  stage  which  sometimes  supervenes  on  a  pro- 
nounced acute  cystitis,  areas  of  ulceration  may  be  observed. 
These  ulcerative  areas  are  usually  at  the  site  of  submucous 
hemorrhages,  a  condition  mentioned  above  in  considering  acute 
cystitis.  In  the  extremely  chronic  form  of  such  ulcerations 
a  deposit  of  lime  salts  occurs,  forming  a  thin  phosphatic  cap. 
To  the  untrained  observer,  these  phosphatic  deposits  may  be 
taken  for  true  calculus  and  by  the  click  elicited  by  a  searcher 
may  easily  deceive  the  surgeon  who  depends  entirely  upon  this 
instrument  for  the  diagnosis  of  stone.  Ulceration,  while  by  no 
means  pathognomonic  of  vesical  tuberculosis,  should  lead  to  a 
strong  suspicion  of  its  probable  presence. 

The  cystoscopic  appearance  in  a  chronic  cystitis  of  long 
standing  is  essentially  different  from  that  of  the  grades  men- 
tioned above.  The  mucosa  is  almost  sclerotic  looking.  The 
epithehal  luster  is  lost  but  the  "light- absorbing"  characteristic 
noted  in  the  subacute  form  is  no  longer  present.  Against  the 
back  ground  of  sclerotic- white,  which  has  lost  the  pinkish-straw 
coloring  that  seems  to  underlie  the  normal  mucosa,  an  occasional 
vessel  is  seen.  The  beautiful  arborescence  and  delicate  anas- 
tomoses which  characterize  the  vascularity  of  the  normal  bladder 
are  no  longer  observed.  The  few  scattered  vessels  seem  to  be 
isolated  and  to  have  lost  their  small  branch-like  terminations. 
Occasionally,  a  cicatrix  may  be  noted,  the  aftermath  of  an  espe- 
cially severe  invasion. 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  97 

Stone. — The  importance  of  the  cystoscope  in  the  diagnosis 
of  vesical  stone  cannot  be  over-estimated.  Erroneous  findings, 
both  positive  and  negative,  are  made  with  such  frequency  as  to 
make  even  the  skilled  surgeon  chary  of  a  diagnosis  made  by  the 
searcher  which  has  not  cystoscopic  confirmation. 

In  the  comprehensive  diagnosis  of  stone  we  are  confronted 
by  the  following  questions: 

(i)  Is  a  stone  present? 

(2)  If  present,  have  we  to  deal  with  single  or  multiple  calculi 
and  how  many? 

(3)  What  is  the  character  of  the  stone  or  stones,  i.e.,  are  they 
of  the  soft  or  hard  variety  and  of  what  size? 

(4)  Is  the  stone  encysted,  enclosed  in  a  diverticulum  or 
impacted  in  and  protruding  from  the  ureter? 

(5)  If  a  click  is  elicited  by  the  searcher,  have  we  to  deal  with 
a  stone  or  a  phosphatic-capped  neoplasm  or  ulcerated  area? 

That  a  knowledge  of  the  above  conditions  is  important, 
especially  if  litholapaxy  is  contemplated,  and  that  such 
knowledge  can  be  obtained  only  by  means  of  careful  cystoscopy, 
will  hardly  be  denied. 

In  the  detection  of  vesical  stone,  the  searcher  may  and  does 
often  fail  for  the  following  reasons: 

(i)  The  stone  may  be  caught  in  a  diverticulum. 

(2)  It  may  be  held  between  the  rugosities  caused  by  conges- 
tion. 

(3)  It  may  lie  in  a  deep  bas  fond  behind  an  over-hanging 
prostatic  ledge.     (See  Fig.  49.) 

Fenwick  has  described  an  atonic  sacculation  of  the  bladder 
occurring  just  behind  the  interureteric  fold  which  may  im- 
prison the  calculus  and  render  its  detection  by  means  of  the 
searcher  extremely  improbable.  Under  such  circumstances  a 
positive  diagnosis  can  be  made  only  by  cystoscopy,  and  the 
frequency  of  such  conditions  is  such  as  to  deserve  much  greater 
recognition  than  is  given  them  by  the  general  profession. 

The  appearance  of  stone  presented  under  cystoscopy  is 
7 


98 


CYSTOSCOPY   AND    URETHROSCOPY 


striking  and  characteristic.  The  coloring  and  shape  vary  with 
the  composition  of  the  calculus.  Kidney  stones  which  have 
but  recently  entered  the  bladder  are  grayish-brown  (uratic)  or 
reddish-brown  (oxalate).  They  may  be  smooth  or  spiculated. 
Stones  which  have  remained  in  the  bladder  for  a  long  period 
or  which  have  formed  in  this  viscus  are  phosphatic  and  vary 
from  a  grayish-white  to  a  dead-white  color.  Their  surface  is 
usually  smooth  and  if  multiple  calculi  are  present  irregular 
facetted  surfaces  appear. 

Partially  encysted  stone  or  stones  which  are  impacted  at 
the  orifice  of  the  ureter  will  be  noted  as  projecting  apparently 


Fig.  49. — Comparison  of  sound  and  cystoscope  for  detection  of  vesical  stones: 
Visible  by  cystoscope,  but  beyond  reach  of  sound.     (Keen's  Surgery.) 


from  the  bladder  wall.  If  the  stone  is  old  it  may  have  a  mush- 
room appearance. 

Stones  which  have  recently  become  lodged  in  diverticula  do 
not  completely  fill  the  cavity.  If  the  diverticulum  be  large  and 
the  stone  comparatively  small,  the  phonophore  devised  by 
Follen  Cabot  and  later  modified  by  Eaton  is  of  service  in 
the  detection  of  the  calculus.  If  the  stone  has  remained  in 
the  diverticulum  for  some  time  it  may  probably  completely 
fill  the  cavity  or  may  mushroom  out  into  the  bladder  cavity. 

Case  illustrated  by  Frontispiece:  Multiple  stones  in  the 
bladder. 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER 


99 


F.  J.  C,  aged  64:  referred  by  Dr.  J.  C.  Parrish,  Vandalia, 
Mo .  Extremely  debilitated  from  prolonged  suffering  and  urinary 
sepsis;  with  bilateral  hypertrophy  of  the  prostate  and  obstruc- 
tion (12  ounces  of  residual  urine,  alkaline,  purulent).  History 
of  ten  years  standing.  Frequent  efforts  at  urination  day  and 
night,  with  occasional  passage  of  small  stones.  Probably  a 
hundred  had  passed  out  this  way,  with  voluntary  urination. 

After  pro\dding  rest  and  restora- 
tive measures  for  several  days,  we 
introduced  the  cystoscope  and  met 
with  the  remarkable  view  presented 
in  the  frontispiece.  A  multitude  of 
calculi  of  varying  sizes,  ranging 
from  that  of  a  grain  of  sand  to  a 
pea;  distributed  over  the  reddened 
and  trabeculated  bladder  in  singles, 
in  groups  and  in  masses. 

After  a  good  view  had  been  taken 
by  everyone  available,  the  task  of 
removing  the  stones  was  begun. 
They  were  washed  out  through  the 
sheath  of  the  Universal  cystoscope, 
about  a  thousand  being  thus  re- 
moved at  the  first  sitting,  and  the 
remainder  of  over  1700  at  the  two  successive  similar  sittings 
(Fig.  50). 

Radiograms  of  both  kidneys  and  ureters  were  taken  and 
showed  no  stone  shadows  in  either. 

Later,  when  the  patient  had  sufficiently  recuperated,  the 
obstructing  prostate  was  removed  by  the  suprapubic  route, 
under  novocaine-spinai  anesthesia,  with  prompt  and  satisfactory 
recovery. 

In  the  cystoscopic  diagnosis  of  stone,  it  seems  hardly  neces- 
sary to  warn  against  mistaking  a  phosphatic-incrusted  neoplasm 
for  a  calculus.     The  incrustation  of  a  growth  is  thin  and  is  readily 


Fig.     50- 

-Multiple 

stones 

(over     1 700) 

removed 

through 

cystoscope. 

lOO  CYSTOSCOPY   AND    URETHROSCOPY 

fragmented  by  tapping  with  the  beak  of  the  cystoscope.  The 
growth  is  usually  readily  observable  and  careful  cystoscopy  will 
establish  the  differential  diagnosis. 

TUMORS 

Tumors. — The  use  of  the  cystoscope  has  demonstrated  the 
fallacy  of  the  older  teachings  as  to  the  rarity  of  tumors  of 
the  bladder.  Vesical  neoplasms  occur  with  a  fair  degree  of 
frequency  and  their  study  has  formed  an  important  part  in  the 
remarkable  advance  made  in  urological  diagnosis.  Unfortu- 
nately their  classification  by  the  different  investigators  has  given 
rise  to  much  confusion.  Kiister  and  Albarran  have  proposed  a 
classification  based  upon  the  prevailing  histological  elements, 
epithelial,  connective  tissue  and  muscular.  From  the  stand- 
point of  histo-pathology,  the  classification  is  as  follows: 

I  Papilloma* 
I  Carcinoma  t 

Adenoma 

Cysts 


Epithelial  Group 


Connective  Tissue  Group 


Sarcoma 
Myxoma 
Fibroma 
Angioma 


Muscle  Group  {  Myoma 

Cystoscopically  considered  we  may  broadly  divide  bladder 
growths  into  two  classes:  (i)  Pedunculated  and  (2)  sessile. 
The  pedunculated  growths  may  present  as  villous- covered  tu- 
mors or  as  smooth  polypi.  The  sessile  tumors  may  have  a  rough- 
ened, warty,  or  excoriated  surface  or  be  comparatively  smooth 
or  "bald"  (Fenwick).     It  is  quite  often  impossible  to  more  than 

*  In  Kiister's  classification  papilloma  is  included  in  the  connective-tissue  group  but 
Davis  (Primary  Tumors  of  the  Urinary  Bladder,  Annals  of  Surgery,  April,  1906)  logic- 
ally places  it  in  the  epithelial  group. 

fDewitski  (Medicinsche  Woche.,  Aug.  7  and  14,  1905)  has  recorded  a  case  of  syn- 
cytioma  malignum. 


Fig.  51. — Cystoscopic  view  of  tumor  of  bladder.     Papilloma. 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  lOI 

guess  at  the  histo-pathology  of  the  growth  from  its  appearance 
through  the  cystoscope.  As  a  fairly  reliable  rule  it  may  be 
stated  that  slender-stalked  growths  are  usuall}'  benign  while 
sessile  tumors  are  generally  malignant.  Apparently  benign 
villous-covered  growths  may  exhibit  malignant  changes,  this 
tendency  toward  malignancy  being  usually  found  at  the  base 
of  the  tumor.  In  the  cystoscopy  of  bladder  growths  the  cys- 
toscopist  is  concerned  principally  in  determining  the  presence 
of  a  neoplasm,  the  number  of  growths  present,  their  appear- 
ance and  location,  their  mode  of  attachment  to  the  bladder 
wall,  i.e.,  w^hether  they  are  sessile  or  pedunculated,  and  the  ex- 
tent of  the  involvement  of  the  wall  in  the  base  of  the  growth, 
all  of  which  are  important  from  the  standpoint  of  subsequent 
treatment  and  prognosis. 

Cystoscopy. — Fenwick  has  divided  the  progress  of  vesical 
new-growths  into  tliree  stages:  (i)  The  latent  stage;  (2)  the 
hematurial  stage;  (3)  the  stage  of  infection.  The  opportunity 
for  examining  the  bladder  cystoscopically  in  the  first  or  symp- 
tomless stage  is  practically  never  presented  and  the  cystoscopist 
is,  therefore,  forced  to  examine  in  the  presence  of  free  bleeding 
and  infection.  The  clouding  of  the  distention  medium  incident 
to  the  hemorrhage  is  operative  against  a  comprehensive  cystos- 
copy and  requires  changes  in  and  additions  to  the  technique 
usually  observed  in  cystoscopy. 

To  control  the  hemorrhage,  st^-pticin  may  be  administered 
internally  and  a  i-iooo  solution  of  adrenal  extract  injected  into 
the  bladder  immediately  before  cystoscopy.  Lately  we  have 
made  use  of  normal  horse  serum  hypodermically  for  the  control 
of  hemorrhage.  The  tendency  of  much  intravesical  instru- 
mentation to  give  rise  to  bleeding  must  be  kept  in  mind  and 
preliminary  manipulations  should  be  reduced  to  a  minimum. 
Within  a  few  minutes  after  the  injection  of  the  adrenal  solu- 
tion the  cystoscope  should  be  introduced — and  it  is  impor- 
tant that  an  instrument  of  the  freely  irrigating  type  be  used — 
and  the  solution  allowed  to  discharge  through  the  sheath  on 


I02  CYSTOSCOPY   AND    URETHROSCOPY 

the  withdrawal  of  the  obturator.  The  required  amount  of 
clear  distention  medium  should  be  rapidly  but  gently  in- 
troduced, the  lens-system  inserted,  the  light  turned  on  and  a 
rapid  search  for  the  growth  instituted.  In  the  event  of  copious 
hemorrhage  quickly  obscuring  the  distention  medium,  free 
irrigation  through  the  instrument  should  be  utilized.  Even  in 
extreme  bleeding,  a  constant  stream  of  irrigating  fluid  will 
keep  the  field  under  immediate  observation  sufficiently  clear 
for  accurate  cystoscopy. 

Cystoscopy  of  a  bladder  which  is  the  seat  of  a  new-growth 
should  be  carried  on  with  much  gentleness  and  strict  adherence 
to  aseptic  technique.  Any  intravesical  manipulation  under 
such  conditions  has  a  decided  tendency  to  produce  bleeding.  If 
cystoscopy  is  done  during  the  hematurial  stage  and  previous  to 
the  supervention  of  infection,  it  is  a  safe  rule  to  be  prepared  to 
operate  immediately  following  the  cystoscopic  examination. 
Fenwick  considers  a  history  of  sudden  painless  "blocking"  of  the 
urinary  stream  in  vesical  tumor  to  be  indicative  of  marked  back- 
pressure effects  and  favors  immediate  operation  as  soon  as  the 
cystoscope  has  confirmed  the  diagnosis.  Unilateral  renal  pain  is 
held  by  the  same  author  to  demand  the  greatest  gentleness  and 
cleanliness  in  cystoscopy. 

Contraindications  to  Cystoscopy.- — If,  in  the  presence  of  a 
pronounced  hematuria,  manual  or  digital  examination  reveals 
infiltration  of  the  bladder  wall,  cystoscopy  is  both  unnecessary 
and  contraindicated.  The  diagnosis  of  an  infiltrating  malignant 
neoplasm  may  be  considered  as  established  and  the  discomfort, 
trauma  and  danger  of  added  infection  incident  to  cystoscopy 
under  such  circumstances  should  be  studiously  avoided.  A 
pronounced  persistent  cystitis  supervening  upon  a  history  of 
profuse  hematuria  is  contraindicative  to  cystoscopy  unless 
followed  by  immediate  operation.  The  indications  are  rather 
for  suprapubic  drainage,  at  which  time  exploration  of  the 
bladder  may  be  accomplished. 


CYSTOSCOPY   OF    THE   DISEASED  BLADDER  IO3 

Location  of  Growths. — While  the  position  a  tumor  occupies 
in  the  bladder  is  influenced  in  a  great  degree  by  the  character  of 
the  growth,  the  area  immediately  surrounding  the  trigonum 
forms  probably  the  most  frequent  location.  The  lateral  and 
posterior  wahs  are  quite  frequently  the  site  of  bladder  growth 
while  it  is  extremely  exceptional  to  find  the  anterior  wall  the 
seat  of  tumor. 

It  is  often  difficult  in  long  pedicled  growths — and  especially 
in  those  whose  villi  are  long  and  tenuous — to  locate  readily 
the  site  of  attachment  of  the  pedicle.  A  growth  springing  from 
the  lateral  wall  may  appear  under  careless  cystoscopy  to  be 
occupying  the  base  or  even  the  opposite  lateral  wall.  It  is 
always  the  part  of  wisdom  to  cause  a  swirl  of  irrigating  fluid  to 
be  directed  against  the  growth  through  the  irrigating  cystoscope 
causing  it  to  float  off  and  up  in  the  distention  medium  and  thus 
disclosing  its  site  of  attachment.  Fenwick*  has  suggested 
change  of  position  on  the  part  of  the  patient  during  cystoscopy, 
thus  causing  the  growth  to  gravitate  to  different  parts  of  the 
bladder.  In  thickly  covered  villous  growths,  it  is  often  difficult 
to  determine  the  size  of  the  pedicle  or  the  condition  of  the  mucosa 
surrounding  the  area  of  implantation.  As  these  two  points  are 
of  great  diagnostic  and  prognostic  importance,  their  determina- 
tion is  important.  Resort  may  be  had  to  the  irrigating  cysto- 
scope {vide  supra)  which  procedure  will  clear  up  the  difficulty. 

Papilloma. — Of  this  form  of  vesical  neoplasm,  there  are  two 
distinct  clinical  types  (i)  the  villous-covered  growth  having  a 
definite  pedicle  and  (2)  the  sessile  warty  patch.  The  latter  is, 
in  reality,  made  up  of  a  number  of  thickly  grouped  papillae 
springing  directly  from  the  mucosa.  These  two  forms  will  be 
described  together. 

The  appearance  of  the  pedicled  villous-covered  growth — the 
so-called  fimbriated  papilloma — is  one  of  the  most  beautiful 
and  interesting  pictures  presented  to  the  cystoscopist.  The 
delicate  fibrillae  float  freely   in   the   distention  fluid  and   are 

*  Tumors  of  the  Urinary  Bladder. 


I04  CYSTOSCOPY   AND    URETHROSCOPY 

readily  agitated,  by  any  movement  which  disturbs  the  fluid, 
much  resembUng  the  movements  noted  in  deUcate  sea-moss 
waving  in  its  watery  environment.  Their  color  is  a  yellowish- 
pink,  looking  very  much  like  small  slender  pieces  of  normal 
bladder  mucosa  which  have  become  detached.  Careful  observa- 
tion of  these  fibrillae  will  disclose  the  presence  of  minute  blood 
vessels  coursing  along  their  length. 

These  villi  differ  greatly  in  size  and  contour.  They  may  be 
of  extreme  tenuity  and  delicacy  or  they  may  present  a  shorter, 
thicker  appearance.  The  villi  are  occasionally  so  stunted  as 
to  be  hardly  observable  and  the  tumor  may  then  appear  to  be  of 
the  "bald"  epitheliomatous  type.  The  viUi  often  present 
branchings  or  off -shoots.  If  bleeding  be  present,  small  streams 
of  blood  will  be  noted  issuing  from  various  parts  of  the  growth. 
If  hematuria  has  been  pronounced,  clots  may  be  observed 
adhering  to  the  tumor.  If  cystitis  has  supervened,  a  film  of 
mucus  may  partially  obscure  the  growth.  It  may  be  the  seat 
of  deposit  of  phosphatic  grit. 

On  observing  the  base,  or  pedicle,  of  villous-covered  benign 
tumors,  it  will  be  noted  to  be  in  most  instances  slender  and  its 
point  of  attachment  to  the  bladder  wall  has  no  surrounding 
zone  of  infiltration.  A  thick,  stunted  pedicle  or  infiltrated  ap- 
pearance of  the  mucosa  surrounding  the  base  should  immediately 
arouse  a  suspicion  as  to  malignancy,  as  it  is  in  the  pedicle  and 
base  that  malignant  changes  in  apparently  benign  growths  are 
observed.  A  slender  pedicle  and  long  villous  processes  are 
prognostic  of  benignancy.  The  fact  that  benign  villous-covered 
growths  occasionally  occur  as  purely  sessile  tumors  must  not 
be  overlooked,  the  villi  in  such  instances  arising  directly  from  the 
vesical  mucosa  without  any  common  pedicle.  Sessility  must, 
however,  be  always  viewed  with  suspicion.  Benign  growths 
are  almost  invariably  single,  though  a  malignant  tumor  may  be 
surrounded  with  benign  papillomatous  "splashings"  or  "tuft- 
ings"  (Fenwick). 

The  location  of  papilloma  is  usually  in  the  neighborhood  of  the 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  I05 

trigone  but  outside  of  it.  We  have  observed  one  case  of  long 
slender -stalked  tumor  in  the  male  whose  point  of  origin  was  the 
urethral  angle  of  the  trigone. 

Carcinoma. — Carcinoma  of  the  bladder  is  observed  as  a 
smooth,  sessile,  infiltrating  growth  or  as  a  pedicled  villous- 
covered  growth.     These  will  be  considered  separately. 

The  Sessile  Growth. — The  one  pronounced  characteristic 
of  this  form  of  tumor  is  its  absolute  sessility.  It  is  usually 
found  posterior  to  the  interureteric  fold  but  in  its  extension  may 
involve  the  trigone. 

It  is  but  slightly  raised  above  the  surrounding  surface  and 
its  edges  merge  gradually  into  the  surrounding  mucosa. 

Its  surface,  comparatively  smooth  in  the  early  stages  of  the 
growth,  becomes  later  cracked  and  roughened  and  devoid  of  its 
epithelial  covering.  From  these  cracks  blood  oozes  and  mixes 
with  the  distention  medium.  White  flakes  of  phosphatic  deposit 
may  be  noted  on  its  surface  and  often  this  phosphatic  incrusta- 
tion is  almost  complete.  If  cystitis  be  present  (and  it  is  usually 
a  factor  before  cystoscopy  is  undertaken)  a  veil  of  muco-pus 
covers  the  surface  and  floats  up  in  the  distention  medium. 

The  color  of  these  sessile  growths,  at  first  reddish  and  marked 
by  a  net-work  of  dilated  vessels,  becomes  later  a  reddish-gray, 
the  color  varying  in  different  portions  of  the  surface.  The 
periphery  of  the  tumor  is  marked  by  clusters  of  glandular 
translucent  vesicles.  These  vesicles  often  extend  up  and  over 
the  surface  of  the  growth,  imparting  to  it  a  roughened  mam- 
millated  appearance.  The  extension  of  these  vesicles  for  any 
distance  from  the  growth  is  indicative  of  wide  submucous 
infiltration  and  is  an  extremely  bad  prognostic  sign. 

The  Villous-covered  Malignant  Growth. — It  is  sometimes 
exceedingly  difficult  to  make  a  cystoscopic  differential  diagnosis 
between  this  form  of  villous-covered  growth  and  the  benign 
villous-covered  tumor.  In  the  main,  the  malignant  tumors  of 
this  class  are  characterized  by  shorter,  denser  villi,  and  a  tend- 
ency to  sessility  and  multiplicity.     If  the  tumor  is  pedicled, 


Io6  CYSTOSCOPY   AND   URETHROSCOPY 

the  pedicle  is  short  and  thick  and  is  devoid  of  the  peculiar 
freedom  of  movement  noted  in  the  slender  pedicle  of  the  benign 
growth.  Satellite  "  splashings  "  are  often  found  m  the  immediate 
neighborhood  and  these  "splashings"  are  usually  benign  in 
character. 

A  careful  observation  of  the  area  immediately  surrounding 
the  site  of  attachment  of  the  pedicle  is  of  great  importance. 
The  mucosa,  instead  of  presenting  the  normal  appearance  noted 
in  the  benign  tumors,  is  injected  with  dilated  vessels.  Grape- 
like, vesicular  bodies,  formed  from  distended  glands,  often  sur- 
round the  base  and  Fenwick  considers  these  as  evidential  of 
deep  iniiltration. 

Sarcoma. — Sarcoma  of  the  bladder  is  a  comparatively  rare 
member  of  the  group  of  vesical  neoplasms,  though  quite  a  goodly 
number  of  cases  have  been  reported.  Senftblen,*  in  1861, 
recorded  the  first  case  and  Wilder,!  in  1905,  reviewed  fifty  cases 
compiled  from  the  literature.  To  these  he  adds  four  others,  a 
total  of  fifty-four  recorded  instances.  Of  these  cases,  twenty- 
six  were  over  forty  years  of  age  and  only  sixteen  under 
twenty. 

The  site  of  origin  of  the  great  majority  of  these  tumors  was 
in  the  immediate  neighborhood  of  the  ureters  or  the  posterior 
wall.  In  the  cases  of  Butlin,  Williams,  Fenwick,  Whitehead  and 
Bunce,  practically  the  entire  bladder  was  involved.  In  the  cases 
of  Siewert,  Eve,  Chaffey,  Baker,  D'Arcy,  Power,  Nicolich  and 
Hinterstoisser,  the  growth  sprang  from  the  anterior  wall.  Such 
a  large  percentage  of  tumors  originating  in  the  anterior  wall — 
a  most  unusual  location  for  bladder  growth- — should  be  kept 
in  mind  as  a  significant  fact  in  the  cystoscopy  of  vesical  tumor. 
Fenwick  concludes  from  his  studies  of  sarcoma  of  the  bladder 
that  in  children  there  is  a  tendency  toward  multiplicity  and 
that  in  the  adult  the  single  growth  is  the  rule.  There  is  no 
rule  as  to  the  gross  appearance  of  these  tumors  or  as  to  their 

*  Archiv    f.  klin.  Chir.,  Berlin,  1861,  Bd  I,  page  128. 
t  Amer.  Jour,  of  the  Med.  Sciences,  Jan.,  1905. 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  I07 

mode  of  attachment  to  the  bladder  wall.  They  are  most  often 
sessile  or  subsessile,  though  pedunculated  growths  occur  with  a 
fair  degree  of  frequency.     Their  growth  is  rapid. 

The  cystoscopy  of  sarcoma  shows  nothing  that  can  be  con- 
sidered characteristic.  Wilder  emphasizes  the  importance  of 
the  cystoscope  in  the  early  diagnosis  of  the  presence  of  sarcoma 
and  points  to  the  case  of  Stankiewicz  as  being  the  only  one  in 
which  recurrence  had  not  taken  place  within  one  year  subsequent 
to  operation.  In  this  case  the  diagnosis  of  the  presence  of  a 
tumor  was  made  by  cystoscopy  and  the  growth  was  no  larger 
than  a  small  cherry. 

Cysts. — Cysts  of  the  bladder,  with  the  possible  exception  of 
those  of  the  mucous  follicles  found  in  the  trigonal  area,  are  of 
extreme  rarity.  Dermoid  cysts  have  been  observed  as  have 
those  caused  by  the  echinococcus. 

Follicular  Cysts. — Cysts  of  the  mucous  follicles  are  not 
infrequently  observed.  They  usually  accompany  a  condition 
of  submucous  infiltration  and  are  of  about  the  same  size  and 
appearance  as  the  cysts  of  Littre's  glands  of  the  urethra.  They 
appear  as  small  translucent  vesicles,  about  the  base  of  which 
careful  observation  will  disclose  a  zone  of  infiltration.  Fenwick 
has  observed  them  at  the  edge  of  tuberculous  patches  and  around 
the  base  of  infiltrating  epithelioma.  They  are  not  uncommon  in 
chronic  cystitis. 

Dermoid  Cysts. — This  rare  form  of  vesical  neoplasm  usually 
presents  as  a  sessile  growth.  In  the  case  observed  by  J.  Block,* 
a  girl  of  eighteen  years,  the  growth  was  located  posterior  and 
to  the  outside  of  the  trigone.  It  was  about  the  size  and  ap- 
pearance of  a  half  of  a  small  raspberry.  Several  fine  hairs  were 
seen  emerging  from  small  depressions  on  the  surface.  It  was  a 
pedicled  growth,  having  a  distinct  fibrous  pedicle.  In  its  incipi- 
ency,  it  was  undoubtedly  sessile  or  subsessile. 

Bilharzia  Disease. — This  disease,  fairly  common  in  Egypt 
and  Africa,  is  of  the  most  extreme  rarity  in  this  country.     In 

*  Amer.  Jour,  of  Med.  Sciences,  April,  1905, 


Io8  CYSTOSCOPY   AND    URETHROSCOPY 

England  quite  a  number  of  cases  have  been  observed  in  soldiers 
who  have  been  on  duty  in  Africa  and  Egypt. 

The  cystoscopy  of  Bilharzia  disease  is  inconstant  and  pre- 
sents nothing  which  may  be  considered  characteristic.  Fenwick 
states  that  the  ova  may  be  deposited  in  the  mucosa  without 
provoking  marked  disturbance  and  appear  "as  small  clumps 
of  white  rice  grains  scattered  over  the  bladder  in  patches." 

Griesinger,  quoted  by  Fenwick,  states  that  the  earliest 
observable  changes  are  scattered  hyperemic  spots.  These 
spots  of  hyperemia,  in  all  probability,  mark  the  points  of  lodg- 
ment of  the  ova  in  the  capillaries.  With  the  emergence  of  the 
ova,  small  hemorrhagic  spots  are  noted. 

In  chronic  cases,  papillomatous  growths  are  often  observed. 
Fenwick  considers  the  continued  irritation  caused  by  the  dis- 
toma  hematobia  to  be  a  cause  of  epithelial  cancer  and  Goeber*  con- 
cludes, from  his  exhaustive  study  of  Bilharzia  disease,  that  cancer 
forms  fully  50  per  cent,  of  the  tumors  arising  from  this  cause. 

Echinococcus. — This  form  of  parasitic  invasion  of  the  bladder 
has  been  observed,  but  it  is  of  exceptional  rarity  among  English- 
speaking  peoples.  Cystoscopically  it  presents  nothing  char- 
acteristic and  we  shall  therefore  dismiss  it  without  further 
comment. 

Varices. — The  existence  of  varices  in  the  bladder,  while 
denied  by  some  writers  and  entirely  ignored  by  others,  has  been 
established  beyond  any  doubt.  They  are  unquestionably  rare 
but  have  been  observed  by  Casper  and  others.  We  have  ob- 
served one  such  case  in  which  there  were  present  pronounced 
varicosities.  The  patient  was  a  middle-aged  woman  suffering 
from  a  marked  cystocele. 

The  cystoscopic  appearance  is  typical.  The  bluish,  dis- 
tended veins  pursue  a  tortuous  course  over  the  mucosa.  View- 
ing them  laterally  they  are  seen  to  project  quite  prominently 
above  the  surrounding  mucosa.  They  are  almost  always  found 
in  the  trigonal  area  or  immediate  neighborhood. 

*  Goeber:     Zeitschrift  f.  Krebsforschung,  last  index  XLIV. 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  IO9 

Myxoma. — This  is  essentially  a  tumor  of  childhood,  being 
rarely,  if  ever,  encountered  after  the  age  of  six  years.  It  is 
extremely  rare.  In  222  cases  of  microscopically  examined 
tumors  observed  by  Nitze,  myxoma  occurred  five  times. 

Myxomata  are  markedly  pedunculated  and  are  quite  often 
multiple.  They  spring  from  any  portion  of  the  bladder.  In 
the  female  they  may  protrude  from  the  urethra. 

Cystoscopically,  they  present  a  smooth  well-vascularized 
surface  and  are  semi-translucent,  their  degree  of  translucency 
depending  upon  the  preponderance  of  the  mucous  element  in 
their  structure.  They  have  no  infiltrated  area  surrounding  their 
site  of  attachment  and  closely  resemble  the  mucous  polypi 
found  in  the  nose. 

Several  mj-xomata  may  arise  from  a  single  pedicle. 

Fibroma. — Pure  fibromata  of  the  bladder  are  rarely,  if  ever, 
found.  They  practically  always  present  the  mixed  t}^e  of 
tumor,  the  papillary  fibroma  (Virchow),  the  fibro- myxoma  and 
the  fibro-myoma.  The  last  form  may  be  considered  a  surgical 
curiosity.  Casper  considers  them  the  forerunners  of  myxoma, 
myoma  and  adenoma,  but  with  this  statement  we  cannot  agree. 
Their  cystoscopic  description  is  that  of  papilloma  and  myxoma. 

Myoma. — The  occurrence  of  myoma  in  the  bladder,  while 
especially  rare,  has  been  demonstrated  as  a  possibiHty  by 
Belfi eld's  case.  They  occur  as  sessile  growths  and  may  attain 
a  large  size.     They  demand  no  especial  cystoscopic  description. 

Adenoma. — This  rare  form  of  vesical  neoplasm  has  been 
observed  twice  by  Nitze.  He  states  that  the  tumor  is  usually 
sessile  and  may  occur  in  any  portion  of  the  bladder,  having  been 
observed  in  the  vertex  where  there  is  normally  no  glandular 
structure.  The  mixed  type — adeno-carcinoma — is  more  com- 
monly observed  than  pure  adenoma. 

Tuberculosis. — In  taking  up  the  cystoscopic  stud}^  of  urinary 
tuberculosis  our  consideration  is  practically  limited  to  that  form 
which  is  a  descending  infection  from  a  tuberculosis  of  the  upper 
urinary  tract.     That  form  of  infection  which  is  simply  an  exten- 


no  CYSTOSCOPY   AND    URETHROSCOPY 

sion  of  tuberculous  involvement  of  the  prostate  and  adnexa 
affords  no  indication  for  cystoscopy  and  indeed,  in  such  involve- 
ment, instrumental  investigation  of  the  bladder  is  distinctly 
contraindicat  ed. 

While  the  possibility  of  primary  vesical  tuberculosis  cannot 
be  denied,  its  occurrence  must  be  of  the  greatest  rarity,  if,  in 
reality,  such  a  condition  ever  exists.  The  cystoscopist,  there- 
fore, may  expect  to  find  the  tuberculous  lesion  in  that  location 
most  liable  to  be  attacked  by  a  descending  infection,  i.e.,  the 
orifices  of  the  ureters. 

It  seems  apropos  at  this  point  to  sound  a  warning  against 
careless  cystoscopy  in  suspected  tuberculous  cases  and  especially 
in  that  class  of  cases  in  which  the  element  of  mixed  infection  is 
slight  or  absent.  A  comparatively  latent  tuberculous  infection 
of  the  bladder  may  develop  most  virulent  characteristics  under 
trauma  and  introduced  infection.  The  utmost  precautions  of 
aseptic  technique  and  gentleness  must  be  observed  or  most 
regrettable  sequelae  may  follow. 

The  appearance  of  vesical  tuberculosis  depends  upon  the 
stage  of  infection  observed  as  well  as  upon  the  degree  of  involve- 
ment. In  the  extremely  early  stage — the  stage  of  congestion 
which  precedes  the  development  of  the  tubercle^the  appearance 
is  not  characetristic.  Small  areas  of  congestion,  characterized 
I  by  an  extremely  delicate  vascularization,  will  be  noted  immedi- 
ately surrounding  one  or  other  of  the  ureteric  orifices,  possibly 
trailing  away  from  it  on  to  the  adjacent  mucosa.  This  extension 
is  practically  always  on  to  the  trigonum  or  posterior  to  the  inter- 
ureteric  ridge. 

Later,  these  areas  of  congestion  become  the  seat  of  minute 
extravasations  and  the  appearance  is  that  of  small  submucous 
hemorrhage.  In  the  center  of  these  hemorrhagic  areas  small 
grayish-yellow    tubercles*    will   be   noted.     Each  hemorrhagic 

*  Fenwick's  observations  are  not  in  accord  with  the  description  given  here,  but  care- 
ful personal  observation  of  proven  cases  justifies  our  description  which  seems  to  coincide 
with  that  of  the  majority  of  observers. 


CYSTOSCOPY   OF    THE   DISEASED   BLADDER  III 

area  may  be  the  seat  of  a  single  tubercle  or  of  multiple 
deposits. 

The  further  course  of  these  tubercles  is  analogous  with  that 
of  tubercles  of  any  other  mucous  surface  and  the  appearance  va- 
ries with  the  stage  of  development.  The  natural  course  is  toward 
ulceration  and  in  the  final  stage  of  progress  of  the  tuber- 
cle, ulcers  are  observed.  These  ulcerations  call  for  especial 
description. 

The  size  and  shape  of  such  ulcers  depend  upon  whether 
the  ulceration  is  formed  from  the  breaking  down  of  a  single 
tubercle  or  from  the  coalescence  of  a  multiple  deposit.  In 
the  former  instance  the  ulcer  has  a  fairly  regular  outline.  In 
the  latter,  the  outline  is  irregular  and  the  ulcer  is,  of  course,  of 
greater  dimensions.  The  edges  are  slightly  raised  above  the 
surrounding  mucosa.  The  base  is  grayish  and  necrotic.  There 
is  a  peripheral  zone  of  extravasation  and  the  line  of  demarcation 
from  the  surrounding  healthy  mucosa  is  sharply  defined. 

The  appearance  of  the  ureteral  orifice  in  a  descending  tuber- 
culous infection  which  has  involved  the  bladder  is  dependent 
upon  whether  the  infection  has  travelled  by  continuity  along  the 
ureteral  mucosa  or  whether  the  bladder  has  become  infect  ed  from 
the  infection- bearing  urine  without  involvement  of  the  ureter  to 
any  pronounced  degree. 

In  the  latter  instance,  the  changes  in  the  orifice  of  the  ureter 
are  not  particularly  marked.  There  may  be  some  slight  puffi- 
ness  of  the  orifice  which  may  be  touched  by  extravasated  areas. 
But  beyond  changes  similar  to  those  characterizing  the  tuber- 
culous deposits  in  the  mucosa,  nothing  characteristic  is  to  be 
observed. 

Where  the  infection  has  been  by  continuity  along  the  ureter, 
marked  distortion  of  the  ureteral  orifice  occurs  and  this  distortion 
is  characteristic. 

In  the  pronounced  infiltration  which  accompanies  the  tuber- 
culous process  in  the  ureter,  there  ensues  a  thickening  and  con- 
sequent  shortening  of   the  ureter — the  so-called   "bow-string 


112  CYSTOSCOPY   AND    URETHROSCOPY 

ureter."  With  this  shortening  of  the  tube,  the  orifice  becomes 
retracted  and  crater-like.  The  normal  ureteral  slit  becomes 
widened  and  stiffened  by  infiltration  until  finally  an  irregular 
crateriform  opening  results.  Ulceration  may  attack  this  thick- 
ened unyielding  ring  with  the  result  that  the  edges  of  the  orifice 
become  ragged  and  covered  with  a  grayish-yellow  slough. 
Casper  describes  a  bullous  edema  with  the  formation  of  numer- 
ous translucent  vesicles  surrounding  the  ureteral  orifice  which  he 
considers  peculiarly  typical  of  a  descending  tuberculosis. 

Where  the  extension  has  been  by  continuity,  another  change 
which  is  quite  characteristic  will  be  noted.  With  the  retraction 
of  the  ureteral  orifice,  the  distance  from  the  vesical  meatus  to  the 
retracted  orifice  becomes  correspondingly  elongated.  A  possible 
congenital  irregularity  of  the  trigone  must  be  taken  into  con- 
sideration, and  without  easily  recognizable  changes  in  the  orifice 
of  the  ureter,  the  elongation  of  one  of  the  ureteral  sides  has  no 
pathologic  significance. 

In  the  diagnosis  of  tuberculosis  of  the  upper  urinary  tract, 
there  is  need  of  great  caution.  It  quite  often  happens  that  the 
kidney  and  ureter  may  be  markedly  involved  without  any  in- 
volvement of  the  bladder.  In  such  instances,  the  only  diagnostic 
sign  to  be  observed  cystoscopically  is  the  retraction  of  the 
ureteral  orifice.  This,  to  the  trained  observer,  is  characteristic, 
but  ureteral  catheterization  with  a  careful  microscopical  exami- 
nation will  make  the  diagnosis  certain;  and  we  are  convinced 
that  careful  technique  in  the  urinary  examination  will  reveal 
the  tubercle  bacillus  in  every  instance  of  urinary  tuberculosis. 

Lymphoid  Tubercle.- — A  condition  which  occasionally  accom- 
panies bladder  tuberculosis,  and  is  also  observed  in  non- tubercu- 
lous bladders  which  are  the  seat  of  cystitis,  is  a  deposit  of  lymph 
in  the  form  of  lymphoid  tubercle.  On  account  of  the  possibility 
of  confusing  this  condition  with  tubercle  of  the  bladder,  we  have 
considered  it  best  to  describe  lymphoid  tubercle  in  connection 
with  the  consideration  of  tuberculosis  in  order  that  the  differ- 
entiation may  be  readily  understood. 


CYSTOSCOPY    OF   THE   DISEASED  BLADDER 


113 


The  question  as  to  whether  there  exists  in  the  mucosa  of  the 
normal  bladder  lymphatic  follicles  is  a  mooted  one,  with  the  pre- 
ponderance of  opinion  favoring  a  negative  view.  The  investiga- 
tions of  Kretschmer,*  whose  review  of  the  literature  has  been 
exhaustive,  are  of  interest.  He  has  compiled  the  findings  of 
different  investigators  as  follows: 

"S.  Alexander  describes  the  occurrence  of  lymphoid  nodules 
or  formations  in  the  urinary  bladder  under  the  name  of  nodular 
cystitis 

"Stoerck   and    Zuckerkandl   recently,    in   describing    their 


Fig.  52. — Cystitis  granulosa  or  lym- 
phoid tubercle  (non-tuberculous).  (After 
Kneise.) 


Fig.  53. — Cystitis       granulosa. 
Kneise.) 


(After 


cases  of  cystitis  glandularis,  found,  besides  the  presence  of 
glands,  areas  of  lymphoid  cells  which  presented  a  follicle- 
like arrangement. 

"In  regard  to  the  presence  of  lymphoid  tissue  in  the  bladder 
normally,  there  are  those  authors  who  maintain  that  lymphoid 
tissue  is  not  a  normal  constituent  of  the  urinary  bladder. 

"For  example,  Piersol  in  his  book  on  Normal  Histology  says 
that  simple  lymphatic  nodules  or  solitary  follicles  are  found  in 
almost  all  mucous  membranes,  those  of  the  bladder  and  sexual 
organs  excepted. 


*  Surgery,  Gynecology  and  Obstetrics,  Nov.,  1908. 


114  CYSTOSCOPY   AND    URETHROSCOPY 

"  Stoerck  says  that  he  examined  a  large  number  of  bladders  in 
infants  in  large  series,  and  from  various  parts  of  the  bladder  for 
the  presence  of  follicles,  with  the  same  negative  results  as  were 
obtained  by  other  authors. 

"According  to  Chiari,  the  mucous  membrane  of  the  bladder 
does  not  normally  contain  lymphoid  tissue.  That  lymphoid 
tissue  in  the  form  of  small  masses  occurs  in  the  urinary  tract  he 
does  not  deny,  but  he  says  that  their  origin  is  in  direct  relation 
with  the  chronic  catarrh  of  this  mucous  membrane. 

"Przewoski  takes  a  similar  view  of  this  subject  and  says 
that,  as  they  are  absent  at  times,  in  adults,  they  cannot  be 
looked  upon  as  a  normal  part  of  the  bladder  mucosa.  He  thinks 
they  can  develop  at  any  period  of  life,  and  draws  attention  to  the 
fact  that  they  occur  in  a  mucous  membrane  which  shows  all  the 
signs  of  inflammation,  and  that  the  catarrhal  conditions  of  the 
mucous  membrane  give  the  best  conditions  for  its  develop- 
ment  

"Taking  a  directly  opposite  view  of  the  ideas  expressed  by 
the  above-mentioned  authors,  there  are  those  who  believe  that 
lymphoid  tissue  is  a  normal  part  of  the  bladder. 

"Stohr  says  that  the  tunica  propria  sometimes  contains 
solitary  nodules. 

"In  describing  the  histology  of  the  pelvis,  ureter,  and  blad- 
der, Bohm  and  Davidoff  state  that  the  mucosa  often  contains 
diffuse  lymphoid  tissue  which  is  more  highly  developed  in  the 
region  of  the  renal  pelvis. 

"Bailey  is  very  positive,  for  he  says  that  the  stroma  (of  the 
bladder)  consists  of  fine,  loosely  arranged  connective  tissue 
containing  many  lymphoid  cells  and  sometimes  small  lymph 
nodules. 

"S.  Alexander  says  that  the  presence  of  lymphoid  tissue  may 
be  looked  upon  as  the  rule  and  its  absence  as  the  exception. 

"  Weichselbaum  found  these  formations  in  five  individuals, 
varying  from  twenty  to  twenty-three  years  of  age,  who  never 
had  had  a  gonorrhea.     He  is  of  the  opinion  that  normally  lymph 


CYSTOSCOPY    OF    THE    DISEASED   BLADDER  II5 

follicles  may  be  present,  but  very  sparingly,  and  that,  not  until 
they  become  swollen  and  enlarged  by  pathological  changes  do 
they  become  visible  microscopically. 

"  Ziegler  holds  a  somewhat  similar  view,  for  he  says  that  when 
the  mucous  membrane  of  the  bladder  contains  small  aggrega- 
tions of  lymphoid  tissue,  which  are  not  uncommon  about  its 
neck,  these  are  apt  to  protrude  from  the  injected  bladder  surface 
as  grayish- white  nodules. 

"Aschoff  found  numerous  follicles  in  one  new-born  female." 

Sabotta  and  McMurrich  state  that  there  exists  in  the  mucosa 
of  the  bladder  lymph  nodules  but  no  true  glands.  In  the  case 
investigated  by  Kretschmer  apparently  true  lymphatic  follicles 
were  found,  but  he  concludes  that  such  findings  must  be  consid- 
ered abnormal. 

The  peculiar  formation  of  lymphoid  tubercles  has  been 
termed  by  Fenwick  "adenoids  of  the  bladder"  though  he 
recognizes  their  true  character.  They  exhibit  a  pronounced 
predilection  for  the  trigonal  area.  In  a  case  examined  post- 
mortem by  F.  J.  Hall  and  described  in  a  personal  communication 
to  us,  the  tubercles  were  scattered  over  the  entire  bladder  mucosa, 
but  this  must  be  considered  most  unusual.  Commonly,  they 
are  noted  on  the  trigone  or  in  its  immediate  neighborhood. 
This  statement  is  borne  out  by  the  observations  of  Fenwick  and 
ourselves. 

Lymphoid  tubercles  are  of  a  peculiar  yellowish,  gelatinous 
appearance  and  are  distinctly  raised  above  the  mucosa.  The 
surrounding  mucosa  has  no  reddish  zone  of  extravasation. 
The  absence  of  hemorrhagic  periphery  and  the  relatively  large 
size  of  the  lymphoid  tubercle  serve  to  differentiate  it  from 
true  tubercle.* 

SIMPLE  ULCER 

Non-tuberculous  Ulceration  of  the  Bladder. — Ulceration  of 
the  bladder  is  usually  noted  as  an  accompaniment  of  severe 

*  Fenwick   cautions  against  mistaking  lymphoid  tubercles  for  actual  tuberculous 
deposits  in  the  presence  of  a  vesical  tuberculosis. 


Il6  CYSTOSCOPY   AND   URETHROSCOPY 

cystitis  and  has  been  given  sufficient  consideration  in  connection 
with  the  study  of  cystitis. 

There  is,  however,  one  form  of  vesical  ulcer  that  deserves 
especial  mention,  the  non- tuberculous  ulcer,  the  etiology  and 
symptomatology  of  which  are  extremely  obscure.  It  is  appar- 
ently idiopathic  in  its  origin,  the  basis  of  which  is  probably  an 
arterial  or  trophic  disturbance,  followed  by  a  localized  necrosis. 
It  has  been  observed,  as  a  rule,  in  males  between  the  ages  of 
twenty  and  thirty,  though  females  and  persons  of  other  ages  are 
by  no  means  exempt.  It  is  usually  noted  posterior  to  the 
interureteric  ridge  and  adjacent  to  and  to  the  inner  side 
of  one  or  the  other  ureteral  orifice.  It  is  a  comparatively  rare 
form  of  bladder  lesion. 

There  is  nothing  characteristic  in  its  appearance  and  it  may 
readily  be  confounded  with  tuberculous  ulceration,  from  which 
it  can  only  be  differentiated  by  the  absence  of  coexisting  tuber- 
culous lesions.  The  tubercle  bacillus  is,  of  course,  not  present 
in  the  urine. 

The  ulcer  varies  in  size  from  one-half  inch  in  diameter  to 
one  and  one-half  inches,  averaging  in  size  three-quarters  of  an 
inch  and  has  a  fairly  regular  outline.  The  surface  is  depressed. 
Its  coloring  is  grayish  and  necrotic  and  there  is  the  tendency 
noted  in  all  forms  of  vesical  ulceration  to  the  formation  of  phos- 
phatic  crust.  The  lesion  is  markedly  chronic  in  its  course  and 
is  unaffected  by  anti- tuberculous  measures.  Occasionally  the 
edge  of  the  ulceration  is  undermined  presenting  the  appearance 
found  in  chancroid. 

Careless  or  rough  instrumentation  occasionally  traumatizes 
the  vesical  mucosa  to  such  a  degree  that  ulceration  follows. 
Before  the  advent  of  the  low- amperage  lamp  in  the  cystoscope, 
burns  of  the  bladder  mucosa  from  the  hot  beak  of  the  instrument 
were  not  uncommon.  These  burns  were  followed  by  subsequent 
sloughing  and  ulceration. 

Traumatic  ulceration  yields  slowly  but  certainly  to  rational 
treatment. 


Fig.    54. — (Above)    edema   bullosum,   in   connection   with    (below)    bilateral   hyper- 

trophied  prostate. 


CYSTOSCOPY   OF   THE   DISEASED  BLADDER  II7 

Edema  Bullosum. — Albarran,  Casper  and  others  have  noted 
the  presence  of  a  submucous  serous  exudate  occurring  in  the 
form  of  blebs  or  bullae  accompanying  inflammatory  processes 
of  the  bladder  and  to  this  submucous  effusion  they  have  given 
the  name  of  Edema  Bullosum.  Bierhoff'*  has.  given  a  most 
excellent  description  of  this  condition. 

The  formation  of  bullae  may  occur  in  any  form  of  cystic 
irritation.  Casper  considers  their  presence  surrounding  the 
orifice  of  the  ureter  characteristic  of  a  descending  tuberculosis. 

The  cystoscopic  appearance  of  bullous  edema  is  fairly  typical. 
The  bullae  present  as  semi-translucent  vesicles,  varying  in  size 
from  that  of  a  pea  to  a  grain  of  wheat.  Their  coloring  and  trans- 
lucency  vary  in  direct  proportion  to  the  amount  of  inflammatory 
hyperplasia  which  has  taken  place  in  their  mucous  covering. 
Their  protrusion  above  the  surrounding  surface  is  occasionally 
so  pronounced  as  to  give  them  a  pedunculated  appearance. 

Bullous  edema  's  practically  limited  to  the  trigonal  area, 
being  seldom  encountered  elsewhere.  The  bullae  seldom,  if  ever, 
occur  singly  and  usually  present  as  a  group  of  "heaped-up" 
vesicles. 

Diverticulation  and  Trabeculation.— Diverticula  of  the  bladder 
are  congenital  or  acquired.  The  former  are  usually  single  while 
the  latter  are  almost  invariably  multiple  and  are  associated 
with  trabeculation.  For  this  reason  we  shall  consider  them 
together. 

Congenital  Diverticula. — Congenital  diverticula  are  com- 
paratively rare.  By  predilection  they  are  usually  situated  justbe- 
hind  the  interureteric  ridge  though  they  may  present  in  any  part  of 
the  bladder.  Cystoscopically  they  appear  as  round  or  oval  open- 
ings. The  size  of  the  opening  is  varied.  The  mucosa,  in  the  ab- 
sence of  infection  or  of  contained  stone,  has  a  normal  vasculari- 
zation and  appearance.  They  are  much  deeper  than  the  acquired 
variety  and  it  is  usually  impossible  to  see  the  distal  end  of  the  sac. 

Acquired  Diverticula. — Acquired  diverticula  are  practically 

*  Medical  News,  Vol.  LXXVII,  1900. 


Il8  CYSTOSCOPY   AND    URETHROSCOPY 

always  multiple  and,  being  the  result  of  sacculation,  or  extrusion 
between  trabeculae  caused  by  long-continued  muscular  spasms  to 
overcome  obstruction  at  the  vesical  meatus,  their  edges  are 
formed  by  trabecular  bands  and  their  orifices  are,  therefore, 
irregular  in  shape.  They  are  comparatively  shallow  so  that  the 
entire  surface  of  the  sac  may  be  seen  during  cystoscopy.  The 
changes  in  their  mucous  lining  partake  of  the  same  character  as 
the  changes  noted  in  the  rest  of  the  bladder  mucosa. 

True  trabeculae  must  be  differentiated  from  that  condition 
which  is  often  observed  during  cystoscopy  in  well  distended 
bladders  in  which  considerable  muscular  spasm  is  taking  place. 
In  the  latter  condition,  muscle  bands  will  be  seen  to  stand  out 
prominently  upon  the  mucous  surface  of  the  bladder.  To  the 
uninitiated,  these  muscle  bands  may  be  taken  for  true  trabeculae 
but  the  absence  of  vascular  and  epithelial  changes  and  of  diver- 
ticula will  readily  serve  to  differentiate  this  condition  from  true 
trabeculation. 

Tabetic  Trabeculation. — Nitze  was  the  first  to  call  attention 
to  the  fact  that  even  in  the  earlier  stages  of  tabes  there  occurred 
a  trabeculation  of  the  bladder  wall  due  to  incoordination  between 
the  detrusors  and  the  sphincters.  This  condition  is  in  some 
cases  quite  marked  and  we  beHeve  with  other  observers,  notably 
Koll,  that  it  is  often  possible  to  make  a  diagnosis  of  tabes 
through  the  cystoscope  even  before  the  classical  symptoms  of 
the  disease  have  developed.  The  trabeculation  is  the  result 
of  atonicity  and  resembles  the  apparent  trabeculation  which  is 
sometimes  observed  during  cystoscopy,  as  the  result  of  over- 
distention  of  the  bladder  accompanied  by  a  certain  amount  of 
spasm.  The  difTerentiation  between  these  two  conditions  is 
important  and  trabeculation  which  is  observed  in  the  absence 
of  distinct  obstructive  conditions  in  the  lower  urinary  tract 
should  always  lead  to  a  suspicion  of  a  possible  cord  involvement. 

Leukoplakia. — The  formation  of  thick  dead-white  plaques — 
the  result  of  epithelial  proliferation — upon  the  bladder  mucosa 
has  been  occasionally  noted  as  the  sequence  of  prolonged  cystic 


Fig.   55. — Trabeculation  and  diverticula  of  bladder  wall.     (Knorr.) 


CYSTOSCOPY   OF    THE   DISEASED   BLADDER  II9 

irritation.  As  in  leukoplakia,  or  leukokeratosis,  taking  place  on 
other  mucous  surfaces,  these  plaques  may  be  considered  as  the 
possible  forerunner  of  epithelioma.  Cystoscopically,  they  ap- 
pear as  irregular  dead-white  patches  slightly  raised  above  the 
surrounding  mucosa  in  which  there  is  a  sparse  vascularization 
and  diminution  of  epithelial  luster. 

They  must  be  differentiated  from  phosphatic  "incrustations" 
of  flat  infiltrating  new-growths.  This  differentiation  can  be 
readily  made  by  tapping  the  patch  with  the  beak  of  the  cysto- 
scope  and  by  the  fact  that  these  patches  are  absolutely  lusterless. 
Occasionally  they  themselves  may  be  the  seat  of  phosphatic 
deposit  but  there  should  be  no  difficulty  in  differentiating  them 
from  infiltrating  malignant  growths. 

Ureteric  Meatoscopy. — The  diagnostic  importance  of  the 
changes  which  are  sometimes  noted  at  the  orifices  of  the  ureters 
consequent  to  disease  of  the  upper  urinary  tract  has  been  much 
insisted  upon  by  certain  writers  on  the  subject  of  cystoscopy, 
notably  Fenwnck.  We  cannot  share  in  their  advocacy  of  this 
form  of  cystoscopic  diagnosis  and  while  positive  findings  of 
diseased  ureteral  orifices  are  of  value  in  indicating  the  presence 
of  pathologic  changes  in  the  corresponding  kidney  and  ureter, 
negative  findings  cannot  be  considered  as  contraindicating  a 
kidney  lesion.  We  are  of  the  opinion  that  ureteric  meatoscopy 
without  exploration  of  the  ureter  and  the  collection  of  the 
separately  catheterized  urines  must  be  considered  of  minor 
importance. 

The  retracted  crater-like  orifice  due  to  a  descending  tuber- 
culosis, the  everted  or  prolapsed  orifice,  the  so-called  cystic 
distention  of  the  ureteric  orifice  and  the  edematous  swelling  of 
the  orifice  due  to  stone  lodged  in  the  vesical  end  of  the  ureter 
are  all  worthy  of  consideration  from  the  standpoint  of  cystos- 
copy. The  first-named  condition  has  been  sufficiently  described 
under  vesical  tuberculosis. 

Eversion  or  Prolapse  of  the  Ureteral  Orifice. — Eversion  of 
the  ureteral  orifice  is  comparatively  infrequent.     It  is  probably 


I20  CYSTOSCOPY   AND   URETHROSCOPY 

the  result  of  long-continued  expulsive  efforts  on  the  part  of  the 
ureter.  It  varies  markedly  in  degree.  In  the  lesser  degrees 
it  may  be  present  at  one  cystoscopy  and  absent  at  another  exami- 
nation. In  one  case  which  we  have  been  enabled  to  cystoscope 
quite  frequently,  eversion  of  one  ureter  orifice  was  well  marked 
on  some  examinations  and  absent  at  others.  A  catheter  inserted 
into  the  prolapsed  orifice  would  reposit  the  everted  mucosa  very 
readily.  The  urine  coming  from  this  side  was  normal  in  every 
particular,  the  other  kidney  being  the  seat  of  disease. 

True  prolapse  of  a  severe  grade  is  rare.  It  has  been  mistaken 
for  new-growth  of  the  bladder  and  at  least  one  case  has  been 
operated  on  under  this  mistaken  impression  with  fatal  results. 
This  case  is  fully  reported  by  Colley*  and  occurred  in  an  infant 
of  eighteen  months. 

There  should  be  no  difiiculty  in  the  cystoscopic  diagnosis  of 
this  condition.  The  eversion  of  the  ureteral  mucosa  through 
an  enlarged  orifice  has  much  the  appearance  of  an  anal  prolapse. 
Fenwick  considers  many  of  the  reported  cases  of  eversion  to 
have  been  examples  of  cystic  distention  or  "ballooning"  of  the 
ureteral  orifice  and  says  that  cystoscopic  differential  diagnosis 
must  be  made  between  the  two  conditions.  The  dissimilarity 
in  the  appearance  of  the  two  conditions  is  so  marked  that  we 
consider  any  mistake  in  classification  to  be  due  to  confused 
terminology  rather  than  to  actual  error  in  diagnosis. 

Cystic  Distention  of  the  Lower  End  of  the  Ureter. — While 
infrequently  met  with,  this  condition  has  been  reported  a  suffi- 
cient number  of  times  to  accord  it  cystoscopic  description.  It  is 
dependent  upon  congenital  atresia  or  narrowing  of  the  ureteral 
orifice.  The  expulsive  force  of  the  ureteral  peristalsis  gradually 
forces  out  the  mucosa  of  the  orificial  end  of  the  ureter  and  it 
becomes  ballooned  (Figs.  56  and  57). 

Afterword. — It  hardly  seems  necessary  to  mention  here  the 
fact  that  uterine  tumors  and  exostoses  from  the  pelvis  may 
impinge  upon  the  bladder  to  the  degree  that  they  may  cause  a 

*Path.  Trans.,  1879,  Vol.  XXX,  page  310. 


CYSTOSCOPY   OF    THE    DISEASED   BLADDER  121 

bulging  or  distortion  on  the  inner  side  of  the  viscus.     Malposi- 
tions of  the  uterus  may  give  the  same  cystoscopic  appearance. 

From  the  standpoint  of  cystoscopy  these  changes  in  the  shape 
of  the  bladder  as  observed  through  the  cystoscope  are  rather 


Fig.  56. — Constricted     ureteral    orifice    and  resulting    uretero-vesical  cyst.     (After 

Knorr.) 


Fig.  57. — Side  view  of  the  same,  with  catheter  introduced.     (Knorr.) 

unimportant.  There  is  a  possibility  of  their  being  mistaken  for 
vesical  tumors  but  the  absence  of  vascular  changes  in  the  mucosa 
and  of  evidences  of  infiltration  should  serve  to  obviate  any  pos- 
sible error.  We  do  not  consider  them  of  enough  importance  to 
award  them  any  further  discussion. 


CHAPTER  VII 
OPERATIVE  CYSTOSCOPY 

In  view  of  the  excellent  and  comprehensive  work  already 
accomplished,  as  well  as  that  prospective,  through  the  instru- 
mentality of  the  several  operative  cystoscopes  on  the  market, 
due  consideration  of  this  subject  is  appropriate. 

Operative  cystoscopy  is  indicated  in  all  cases  in  which  it  can 
accomplish  the  surgical  purpose  in  view — the  removal  of  a  for- 
eign body  or  the  remedying  of  a  surgical  condition — that  can 
be  accomplished  otherwise  only  by  opening  the  bladder.  It 
goes  without  saying  that  this  mode,  if  successful,  is  less  heroic 
and  more  readily  acceptable  to  the  patient  than  a  cutting  opera- 
tion would  be. 

But  there  are  various  factors  and  conditions  that  have  a  bear- 
ing on  the  appropriateness  of  operative  cystoscopy  to  a  given 
case:  The  tumor  or  lesion  or  foreign  body  itself,  its  size,  location, 
nature;  the  extent  of  involvement  of  the  vesical  structures;  the 
capacity  of  the  bladder  and  its  tolerance  of  instrumentation; 
the  fortitude  of  the  patient;  the  caliber  of  the  urethra,  etc.,  and 
finally,  the  skill  of  the  operator  and  his  familiarity  with  the 
technique  of  such  work. 

If  the  nature  of  a  growth  or  its  extent  of  involvement  is  such 
as  to  indicate  that  removal  by  this  method  will  not  give  the  last- 
ing results  offered  by  the  more  radical  cutting  measures,  the 
cystoscopic  method  is  not  to  be  chosen.  But  it  is  not  yet  deter- 
mined that  the  cutting  methods  do  give  more  lasting  results  or 
greater  freedom  from  recurrence  in  cases  of  adventitious  vesical 
growths.  That  question  is  still  under  discussion.  It  is  estab- 
lished* that  Nitze  removed  by  cystoscopic  methods  150  non- 

*Knorr,  Cystoscopy,  1908,  page  168. 


OPERATIVE    CYSTOSCOPY  1 23 

malignant  tumors  from  the  unopened  bladder,  with  only  one 
death  and  three  recurrences.  The  records  of  open  operative 
methods  do  not  furnish  anything  to  compare  with  these  figures, 
which  make  an  overwhelming  argument  for  operative  cystos- 
copy in  non-malignant  growths  where  it  is  practicable — both 
from  the  standpoint  of  operative  mortality  and  of  freedom  from 
recurrence. 

.  It  is  further  established  that  open  operations,  with  the  ex- 
tensive handling  and  manipulation  required  in  removing  vesical 
growths,  are  prone  to  contribute  to  further  inoculation  and  dis- 
semination of  such  growths  at  other  points  in  the  vesical  mucosa. 
Even  excessive  care  in  the  handling  of  such  tumors,  by  means  of 
forceps  alone,  etc.,  has  not  furnished  exemption  from  such  sur- 
gical inoculation;  so  that  operations  have  been  devised  with  the 
especial  object  in  view  of  preventing  this  unfortunate  occurrence 
— such  as  the  transperitoneal  mode  of  attack,  as  recommended 
by  Harrington  (Annals  of  Surgery,  1893)  and  popularized  by 
Mayo. 

It  cannot  be  conceded  that  lack  of  equipment,  of  skill  or 
ability  in  cystoscopic  methods,  on  the  part  of  the  surgeon, 
furnishes  legitimate  reason  for  withholding  the  benefits  of  opera- 
tive cystoscopy  where  it  is  demanded.  Tracheotomy  and  in- 
tubation bear  a  similar  relationship.  The  safer  and  more  con- 
servative method  is  the  one  to  be  applied  when  it  is  demanded, 
and  it  is  incumbent  on  the  surgeon  who  accepts  such  cases  to 
prepare  himself  for  applying  the  approved  method. 

Such  a  choice  may  stand  between  the  life  and  death  of  a 
patient;  as,  witness  the  large  difference  between  the  death-rate 
of  litholapaxy  and  that  of  the  open  methods  of  removing  calculi 
from  the  bladder,  i.e., approximately  2.4  per  cent,  for  litholopaxy, 
and  from  10  to  13  per  cent,  for  the  lithotomies — showing  the 
strikingly  greater  number  who  die  from  cutting  methods  as 
compared  with  the  non-cutting  ones. 

While  possibly  not  always  justified  by  actual  conditions,  it  is 
a  fact  that  patients  are  habitually  influenced  by  fear  and  appre- 


124  CYSTOSCOPY   AND   URETHROSCOPY 

hension  when,  contemplating  a  cutting  operation,  and  are  prone 
to  procrastinate  and  postpone  measures  for  relief  until  serious 
secondary  complications  are  established,  the  kidneys  involved, 
etc.  It  is  probable  that  many  of  these  would  more  readily 
accept  the  cystoscopic  methods  of  relief  if  presented  to  them, 
especially  when  accompanied  with  an  explanation  of  their 
freedom  from  the  necessity  of  general  anesthesia  and  of  lying 
in  bed  for  one,  two  or  three  weeks  in  convalescence  from  a  cutting 
operation. 

It  may  reasonably  be  asserted,  therefore,  that  where  opera- 
tive cystoscopy  is  appropriate  and  applicable  it  should  be  given 
the  position  of  choice. 

The  field  of  operative  cystoscopy  has  heretofore  been  con- 
fined almost  exclusively  to  the  bladder  and  its  contents,  but 
the  experience  of  the  authors  in  operative  cystoscopy  of  the 
upper  urinary  tract  has  been  sufficiently  encouraging  to  justify 
the  division  of  the  subject  into:  I.  Operative  Cystoscopy  of 
the  Bladder;  II.  Operative  Cystoscopy  of  the  Ureter. 

The  objects  to  be  accomplished  in  the  first  of  these  divisions 
are  the  following : 

1.  Crushing  and  removal  of  stones. 

2.  Removal  of  foreign  bodies:  hairpins,  twigs,  catheters, 
ligatures,  etc. 

3.  Removal  of  pieces  of  growth  for  investigation. 

4.  Removal  of  tumors  and  cauterization  of  their  bases. 

5.  Fulguration  or  application  of  the  high-frequency  current 
to  vesical  tumors. 

6.  Fulguration  or  cauterization  of  ulcers  or  ulcerated  areas 
in  the  vesical  mucosa;  of  varices,  cysts,  etc. 

7.  Curettement  of  ulcerated  areas,  and  the  topical  applica- 
tion of  strong  solutions  to  the  site  affected. 

The  second  of  the  divisions  embraces  the  following  objects 
for  accomplishment: 

I.  Dilatation,  divulsion  or  incision  of  a  strictured  ureteral 
orifice. 


OPERATWE    CYSTOSCOPY  1 25 

2.  Removal  of  stone  from  the  ureter, 

3.  Gradual  dilatation  of  stricture  at  any  point  of  the  ureter. 

4.  Securing  the  closure  of  a  fistula  of  the  ureter  at  any  point. 

5.  By  dilatation,  irrigation  and  the  injection  of  oil  into  the 
ureter  to  promote  the  descent  of  a  stone  or  stones  impacted  high 
up  in  the  ureteral  channel  or  even  in  the  renal  pelvis. 

OPERATIVE  CYSTOSCOPES 

To  meet  the  varied  requirements  of  operative  cystoscopy 
much  ingenuity  has  been  displayed  in  the  production  of  the 
several  instruments  on  the  market.  First  in  the  lists  were 
the  instruments  of  Nitze  and  of  Casper;  later,  others  were 
introduced,  exhibiting  more  or  less  individuality  in  their 
objects  or  their  construction.  The  operative  cystoscopes 
of  Kolischer,*  of  Mainzer,  Mirabeau,t  and  of  Latzko|  were 
purposed  for  the  female  bladder  only,  and  were  based  on  the 
''direct"  plan  of  access,  after  the  manner  of  Brenner.  Kelly 
and  Pawlik's  instruments  were  for  females  only,  and  were  used 
with  air  distention,  secured  by  postural  methods  (knee-chest 
position).  The  operative  cystoscope  of  Bransford  Lewis, §  pre- 
sented in  1904  (Fig.  58)  was  capable  of  being  used  in  either 
male  or  female,  with  either  air  or  water  distention,  under  control 
of  rubber  bulb  for  the  former,  and  hydrostatic  pressure  for  the 
latter;  thus  affording  freedom  from  reliance  on  posture  to  secure 
distention  of  the  bladder. 

Similar  instruments  were  introduced  in  1905  by  Luys  and 
by  Cathelin,  appropriate  for  both  male  and  female  bladders 

For  vesical  operative  cystoscopy  the  cystoscope  of  Nitze  is 
the  one  best  known  and  most  highly  esteemed,  that  fact  being 
based  both  on  the  large  experience  of  its  author  with  this  instru- 

*  Wiener  med.  Presse,  1897,  No.  52. 

t  Centralbl.  f.  Gynecologic,  1900,  No.  36. 

t  Wiener  klin.  Rundschau,  1900,  No.  37. 

§  Trans.  Miss.  Valley  Med.  Assn.,  Oct.  11,  1904. 


126 


CYSTOSCOPY   AND   URETHROSCOPY 


Fig.  58. — The  Bransford  Lewis  Operating  Cystoscope  (1904);  SH.,  sheath; 
OB.,  obturator;  H.,  lens-telescope,  with  perforated  collar  for  passage  of  the  acces- 
sory instruments. 


=^^ 


THE    KNY-SCHEERER   CO.N.Y. 


<...      u 


THE  KNY-  SCHEERER  CO.N.Y. 


Fig.  5q. — Accessories  for  author's  operating  cystoscope:  i,  alligator  forceps; 
2,  ureteral  scissors;  3,  ureteral  dilator;  4,  flexible  ureteral  forceps;  5,  bulb-aspirator; 
6,  cautery;  7,  catheter  carrier. 


OPERATIVE    CYSTOSCOPY  I  27 

ment  and  on  its  individual  merits.  Its  main  objects  are,  the 
ensnaring  and  removal  of  a  pedunculated  vesical  tumor  (papil- 
loma) ;  the  cauterization  of  the  base  after  removal;  the  crushing 
and  removal  of  stones  of  moderate  dimensions;  the  grasping  and 
removal  of  foreign  bodies. 

The  Nitze  operative  cystoscope  consists  of  an  inner  telescope, 
and  an  outer  sheath.  The  telescope  contains  the  lamp  and  the 
prism  for  observation.  The  sheath  is  made  in  several  forms, 
according  to  whether  it  contains  a  platinum  wire  snare  or  a  cau- 
tery mounted  on  porcelain.  The  sheath  has  an  irrigating  channel 
and  rubber  tubing  for  the  purpose  of  running  water  in  and  out  of 
the  bladder  after  the  introduction  of  the  cystoscope.  To  the 
sheath  that  bears  the  wire  snare  is  attached  the  apparatus  for 
moving  the  wire,  one  strand  at  a  time,  back  and  forth,  in- 
creasing or  decreasing  the  size  of  the  loop. 

Technique. — First,  unscrewing  the  beak,  the  particular 
sheath  desired  for  use  is  slipped  over  the  shaft  of  the  telescope 
and  the  beak  is  replaced.  With  these  two  parts  closed  tightly, 
the  whole  instrument  is  passed  into  the  bladder.  The  telescope 
is  pushed  forward  through  the  sheath,  which  exposes  the  lamp 
and  prism  and  permits  a  view  of  the  vesical  contents,  including 
the  inner  end  of  the  sheath  itself,  whence,  at  will,  the  wire  loop 
is  made  to  emerge  by  means  of  the  mechanism  before  mentioned. 

If  a  pedunculated  polyp  is  the  object  of  the  attack,  it  is 
brought  into  view,  encircled  with  the  snare,  when,  with  or  with- 
out the  addition  of  galvanic  heat,  the  loop  is  contracted,  the 
pedicle  compressed  and  finally  severed.  Unless  the  resulting 
hemorrhage  is  too  severe,  the  sitting  may  be  completed  with 
cauterization  of  the  base  or  stump  of  the  tumor;  for  which  a 
sheath  with  porcelain-covered  cautery  is  appropriate. 

When  the  tumor  is  too  large  to  be  removed  all  at  one  time 
several  sittings  may  be  required,  a  portion  only  being  remo\ed 
by  the  loop  each  time,  until  finally  the  base  is  reached  and  the 
terminal  cauterization  applied. 

In  other  instances,  where  the  attachment  is  sessile  or  there 


128  CYSTOSCOPY   AND   URETHROSCOPY 

are  ulcerated  areas,  the  cautery  itself  is  the  agency  utilized. 
To  meet  the  demands  of  differing  locations  and  sizes  of  tumors, 
several  sheaths  have  been  constructed,  with  beaks  of  differing 
lengths. 

With  the  lithotriptor  not  only  may  calculi  of  fair  size  and 
density  be  seized  under  observation  and  crushed  for  extraction 
by  subsequent  washing,  but  the  fragments  left  over  after  ordi- 
nary litholapaxy  may  be  detected,  seized  and  removed  or  further 
crushed  and  removed;  thus  rounding  out  an  operation  which, 
though  brilliantly  executed,  is  sometimes  marred  by  leaving 
in  a  flake  or  fragment  of  stone,  that  later  acts  as  a  nucleus  for 
further  stone  formation  and  recurrence. 

The  Casper  model  of  operative  cystoscope  is  composed  of 
sheath,  irrigating  tube,  galvano-cautery,  and  cold  snare.  Casper 
does  not  deem  it  necessary  or  desirable  to  heat  the  snare  but 
prefers  the  cold  one.  With  the  same  instrument  there  are  also 
a  sharp  curette,  and  forceps  for  the  removal  of  foreign  bodies. 

Although  the  operative  cystoscopes  of  Mirabeau,  Mainzer 
and  Kolischer  are  built  on  the  Brenner  direct-vision  plan,  they 
are  supplied  with  lenses  and  are  used  with  water  as  a  distending 
medium. 

For  vesical  operative  cystoscopy  all  instruments  adopting 
the  direct-vision  plan  labor  under  a  certain  definite  disadvantage: 
They  are  incapable  of  working  at  a  right- angle  or  "around  the 
corner."  The  direct  (forward)  view  is  the  only  one  furnished 
by  them,  and  this  does  not  permit  access  by  them  to  the  anterior 
wall  of  the  bladder.  It  is  true  that  most  adventitious  growths 
and  pathological  conditions  of  the  bladder  are  located  at  the 
trigone  or  on  the  posterior  wall  in  the  neighborhood  of  the  ure- 
teral orifices,  within  reach  of  the  direct-vision  models,  but  a 
certain  small  proportion  of  them  do  not  follow  this  rule  but  are 
located  on  the  anterior  wall,  outside  of  their  sphere  of  activity. 
While  relatively  few  in  number,  such  cases  must  be  reckoned 
with  in  operative  cystoscopy. 

The  air  cystoscopes  of  Pawlik,  Howard  Kelly,  Luys,  Cathelin 


OPERATIVE    CYSTOSCOPY 


129 


and  Bransford  Lewis  may  be  classed  as  similar  in  their  main 
features  yet  with  points  of  essential  difference.  Those  of 
Pawlik  and  Kelly  are  designed  for  females  only,  are  used  with 
external  illumination  (head  mirror),  and  the  air  distention  of  the 
bladder  is  obtained  by  postural  methods;  while  the  other  instru- 
ments mentioned  are  adapted  to  both  males  and  females,  are 
equipped  with  cold  lamp  internal  illumination,  and  their  air- 
cocks  and  insufflation  arrangements  for  effecting  forced  inflation 
make  them  independent  of  postural  necessities.  In  males  it  is 
inexpedient  to  try  to  secure  distention  of  the  bladder  by  knee- 


GZfe;e= 


Fig.  60. — Bransford  Lewis  air  cystoscope.     1900. 

chest  posture;  it  occasions  too  much  of  a  strain  on  the  patient, 
both  generally  and  locally,  and  the  bladder  does  not  usually 
dilate  satisfactorily.  Neither  is  the  view  obtained  at  all  satis- 
factory. In  females  the  knee-chest  posture  usually  secures 
sufficient  dilatation  of  the  bladder,  but  at  most  it  is  awkward 
and  embarrassing  for  the  patient  and  uncomfortable  for  the 
operator;  and  does  not  offer  any  advantages  not  possessed  by 
the  patient  lying  on  her  back  or  in  the  lithotomy  position — a 
much  more  natural  and  acceptable  one.  While  it  is  a  fact  that 
in  most  women  the  exaggerated  lithotomy  position,  with  eleva- 
tion of  the  pelvis,  will  produce  dilatation  of  the  bladder  sufffcient 
9 


130  CYSTOSCOPY   AND   URETHROSCOPY 

for  use  with  the  cystoscopes  of  Kelly  and  Pawlik  (unequipped 
with  forced  inflation  bulb,  etc.),  it  also  is  a  fact  that  there  are 
numerous  exceptions  to  this  rule;  exceptions  in  which  the  bladder 
is  too  inflamed  and  tender  and  its  tonicity  too  great  to  permit 
of  satisfactory  dilatation  through  this  comparatively  mild  (and 
in  such  instances,  inefflcient)  means.  Therefore  it  is  of  much 
advantage  to  be  in  position  to  control  the  dilatation  by  means  of 
forced  inflation  with  air-bulb,  if  air  is  used,  or  by  hydrostatic 
pressure  if  water  be  the  distending  medium.  Moreover,  it  is 
of  equally  great  technical  advantage  to  work  with  the  internal 
illumination  of  a  cold  electric  lamp,  carried  in  the  beak  of  the 
instrument,  as  compared  with  the  endeavor  to  use  the  unstable 
head  mirror  as  a  source  of  illumination,  with  its  ever-changing 
distances  and  alignment. 

The  Bransford  Lewis  Operating  Cystoscope. — Regarding  its 
sphere  of  action,  the  following  considerations  apply  to  this 
instrument:  For  general  intravesical  operative  work,  its  scope 
is  not  as  great  nor  as  broadly  serviceable  as  the  Nitze  or  Casper 
instruments;  but  on  the  other  hand,  it  is  very  much  simpler  in 
its  construction  and  in  its  use;  while  for  intraureteral  work  it 
presents  advantages  not  possessed,  it  is  thought,  by  any  of  the 
other  instruments.  In  fact,  it  has  been  developed  with  this 
kind  of  work  particularly  in  view;  and  ten  years'  use  has 
brought  the  conclusion  that  it  has  well  fulfilled  the  mission 
designed  for  it. 

Instrument  and  Technique. — This  instrument  (Fig.  58)  con- 
sists of  a  tubular  sheath,  Sh,  with  a  cold  lamp  throwing  its 
light  from  the  convexity  of  its  beak  only,  as  this  is  a  direct- 
vision  instrument  and  requires  no  lateral  illumination. 

Air-cock  i  connects  with  the  large  interior  channel  of  the 
sheath,  and  is  used  to  supply  additional  air  or  water  to  the  blad- 
der as  desired,  during  manipulation  or  observation.  Cock  2 
connects  with  the  smaller  tube  2-3,  which  is  utilized  for  aspir- 
ating excess  of  fluid  or  blood,  etc.,  from  the  bladder  during  man- 
ipulation.    The  obturator,  Ob,  fills  out  the  sheath  during  its 


OPERATIVE    CYSTOSCOPY 


131 


A>=°^ 


B-^^ 


WnrVLtX   ELECTMC  Mrg.  CQ  uvc. 
/I/SW   YORK 


ex 


D 


Fig.  61. — Appurtenances  to  Bransford  Lewis  universal  and  operating  cystoscope, 
model  1914.  A.  Flexible  biting  forceps;  B,  scissors;  C,  stone  forceps;  D,  ureteral 
dilator;  E,  volcellum  forceps. 


V/APFllR  ELECTFIC  MFG.  CO.  INC. 

NEW  YORK 


Fig.    62. — The    Bransford    Lewis    combined    universal    and    operating    cystoscope 
latest  model  1914.     A,  Forceps  in  use  by  direct  method;  £,  Same,  by  indirect  method. 


4^ 


© 


e 


IJ 


{  12         14        16        18        20    1 
Fig.  63. — Dr.  Leo.  Buerger's  ureteral  dilators. 


132  CYSTOSCOPY   AND    URETHROSCOPY 

introduction  into  the  bladder;  after  which  the  obturator  is 
withdrawn  and  is  replaced  by  the  perforated  ocular  window. 
The  perforation  in  the  window  may  be  closed  by  a  metal  plug 
(not  shown  in  the  illustration)  when  the  cystoscope  is  in  use  for 
observation  only;  or  it  permits  the  passage  of  the  several  acces- 
sories, forceps,  etc.,  when  in  use  for  operative  purposes.  The 
adjustment  of  accessories  to  the  perforation  and  to  the  window 
is  such  that  the  distending  medium,  water  or  air,  is  retained  in 
the  bladder  during  the  work.  When  in  place  for  use,  the  several 
accessories  hug  the  floor  of  the  inner  channel,  leaving  the  greater 
part  of  the  space  above  for  vision.  The  field  of  view  is  not 
large  at  one  time,  but  the  survey  is  made  by  moving  the  instru- 
ment in  various  directions;  by  which,  successively,  the  trigone, 
the  base,  the  posterior  and  lateral  walls  and  some  of  the  apex 
are  brought  into  view.  If  water  be  chosen  as  the  distending 
medium,  the  field  of  vision  may  be  enlarged  considerably  by 
using  the  direct  lens  telescope,  H,  which  also  passes  through  the 
perforation  in  the  window.  Lenses  are  impracticable  when  air 
is  used,  as  they  tend  to  become  smeared  with  mucus  and 
obscured.  As  the  instrument  is  capable  of  being  used  with 
either  water  or  air  as  a  distending  medium  the  operator  is  in 
position  to  exercise  his  preference.  In  using  air-distention  it  is 
desirable  to  keep  the  field  as  free  from  fluid,  urine,  blood,  etc., 
as  possible,  to  which  end  the  accessory  aspirating  tube,  2-3,  is 
utilized. 

Accessories. — The  several  instruments  accessory  to  the 
operating  cystoscope  are  shown  in  Fig.  61.     They  consist  of: 

1.  A  straight  alligator  forceps,  i,  for  use  either  in  the  ureter 
or  bladder,  for  grasping  and  removing  a  small  stone  or  foreign 
body. 

2.  Flexible  ureter  forceps.  4,  that  may  be  opened  and  closed 
at  will,  even  though  in  a  curved  or  double-curved  position;  to  be 
passed  into  a  ureter  for  one  or  two  inches,  following  the  pelvic 
curve  of  that  organ,  and  made  to  grasp  a  ureteral  stone  impacted 
there.     It  is  made  like  a  bullet  forceps,  both  for  the  purpose  of 


OPERATIVE    CYSTOSCOPY  I33 

obtaining  a  better  grasp  of  a  ureteral  calculus  and  also  to  avoid 
injury  to  the  ureteral  mucosa  when  opened  up  within  the 
channel.  In  a  number  of  instances  the  author  has  succeeded  in 
passing  it  as  far  as  two  inches  up  the  ureter.  If  the  ureter  is 
dilated  the  forceps  may  be  passed  even  further  than  that. 

3.  Ureteral  scissors,  2,  for  snipping  the  orifice  of  a  strictured 
ureter. 

4.  Ureteral  dilator,  3.  It  is  introduced  into  a  stenosed 
ureter  closed  and  is  then  stretched  widely  as  it  is  withdrawn  or 
while  remaining  in  one  position. 

5.  Galvano-cautery  point  or  blade,  6. 

6.  Ureteral  catheter-carrier,  7,  for  transmitting  ureteral 
sounds  or  catheters. 

7.  Suction  bulb,  5. 

8.  Lens  telescope,  H,  for  direct  observation. 

Mode  of  Use. — To  facilitate  operative  work  with  this  instru- 
ment the  patient  should  be  on  a  well-arranged  cystoscopic  table, 
capable  of  giving  marked  elevation  of  the  pelvis  when  required, 
and  supporting  the  legs  in  comfortable  leg-crutches,  rather  than 
foot  rests.  Ample  anesthesia  must  be  provided,  to  secure  entire 
relaxation  and  non-resistance  of  the  bladder,  as  well  as  quietude 
on  the  part  of  the  patient.  (For  remarks  on  anesthesia,  see 
page  23). 

One  must  determine  whether  he  is  to  use  air  or  water  as 
a  distending  medium  for  the  bladder.  If  there  is  much  hemor- 
rhage, or  reason  to  believe  there  will  be  such  incident  to  the 
procedure — as  often  occurs  in  connection  with  vesical  work  of 
this  kind — it  may  be  best  to  resort  to  air-inflation.  Whereas, 
water  may  be  readily  clouded  and  the  view  obscured  by  such 
influences,  when  used  as  a  distending  medium,  air  is  not  so 
affected.  With  the  patient  in  the  exaggerated  lithotomy  posi- 
tion any  accumulating  blood  or  pus  wiU  tend  to  gravitate  toward 
the  summit  of  the  bladder,  if  distended  with  air,  thus  keeping  a 
clear  field  for  operative  work  in  the  neighborhood  of  the  trigone, 
the  ureteral  openings,  the  base,  etc.     If  the  fluid  accumulation 


134  CYSTOSCOPY   AND   URETHROSCOPY 

becomes  sufficient  to  interfere  with  the  operative  field  it  may  be 
drawn  out  by  use  of  the  aspirating  bulb,  or  by  opening  the  cock 
leading  to  the  vacuum  bottle,  the  beak  end  of  the  cystoscope 
being  held,  meanwhile,  in  the  pool  of  fluid. 

As  the  air  tends  gradually  to  escape  during  manipulations,  it 
is  advisable  to  have  an  assistant  keep  up  regular  and  moderate 
insufflation  with  the  double  rubber  bulb  supplied  for  the  purpose. 
Care  must  be  exercised  lest  too  great  air  pressure  be  supplied. 
While,  if  used  with  due  regard  to  this  precaution,  no  harm  can 
result,  cases  have  been  reported  in  which  a  break  in  the  continu- 
ity of  the  mucosa  at  some  point  has  permitted  the  passage  of  air 
into  the  tissues  and  given  rise  to  emphysematous  accumulations 
that  caused  annoyance  and  anxiety.  We  are  not  aware  that  any 
such  accident  has  proved  fatal,  and  probably  there  will  be  no 
fatality  from  such  a  cause,  but  it  is  just  as  well  to  avoid  any  such 
possibility  by  remaining  within  the  limits  of  reason  and  modera- 
tion in  all  manipulations  within  the  urinary  tract. 

It  must  be  remembered  that  water  is  a  medium  more  natural 
and  more  acceptable  to  the  bladder  than  air,  and  arouses  much 
less  irritation  or  resistance  than  does  air.  When  the  work  is  to 
be  done  in  the  ureter,  or  will  probably  be  unattended  by  severe 
bleeding  or  clouding  of  the  fluid,  water  may  be  chosen  as  a  dis- 
tending medium.  It  is  best  supplied  by  gravity  from  a  glass  irri- 
gator, about  two  feet  above  the  level  of  the  patient.  When  used, 
the  direct- view  lens  telescope  may  be  used  with  it,  or,  if  pre- 
ferred, the  ocular  window  only;  in  which  case  an  unbroken 
column  of  water  must  be  maintained  between  the  window  and 
the  interior  of  the  bladder.  The  smallest  bubble  in  the  cysto- 
scope sheath  will  obscure  the  view.  Therefore  the  window 
should  be  adjusted  while  the  water  is  running,  thus  expelling  all 
bubbles.  With  conditions  properly  adjusted  an  excellent  and 
clear  view  is  obtained  in  this  way,  though  the  field  is  not  a  large 
one,  as  previously  mentioned.* 

*The  latest  model  (1914)  of  the  author's  cystoscope  (see  page  1:31)  is  used  only 
with  water-distention,  because  of  the  many  advantages  and  fewer  objections  per- 
taining to  it. 


OPERATIVE    CYSTOSCOPY 


135 


Cauterization. — This  may  be  accomplished  in  two  ways  with 
this  instrument:  By  direct  applications  of  chemical  cauterants, 
nitric  acid,  nitrate  of  silver,  etc.,  on  a  cotton- tipped  probe  or 
applicator,  or  by  means  of  the  alligator  forceps,  passed  through 
the  window  and  sheath  of  the  cystoscope;  or  the  cautery  blade, 
6,  Fig.  59,  may  be  brought  to  livid  heat  by  the  galvanic  current. 

In  using  the  electric  current  for  the  double  purpose  of  illu- 
mination and  cauterization,  it  must  be  remembered  that  when 
using  the  ordinary  rheostats  or  controllers  for  illumination  two 
separate  and  independent 
sources  of  electricity  should  be 
utilized;  for  instance,  while  the 
street  current  is  passed  through 
the  current  controller  and  serves 
for  illumination,  a  storage  bat- 
tery should  supply  electricity 
for  the  cautery  current,  with 
a  large  cable  adapted  to  cau- 
tery purposes.  Occasionally, 
under  the  circumstances  just 
mentioned,  or  indeed  during  the 
performance  of  an  ordinary 
cystoscopy  or  endoscopy,  the 
operator  or  patient  receives  an 
electric  shock  of  more  or  less 
severity  by  the   grounding    of 

the  current  through  a  moist  tile,  wood  or  granitoid  floor.  A 
medical  friend  of  the  author's  was  knocked  to  the  floor  uncon- 
scious by  such  an  occurrence,  on  one  occasion,  and  it  was  several 
days  before  he  fully  recovered  from  the  effects  of  the  stroke. 
For  the  purpose  of  avoiding  the  possibiUty  of  such  an  accident, 
Mr.  Wm.  A.  Phillips,  of  St.  Louis,  has  made  for  the  author  an 
induction  rheostat  (Fig.  64)  which  not  only  gives  complete 
security  in  this  respect  but  supplies  gradations  of  light-regulation 
so  finely  drawn  as  to  completely  avoid  the  jump-increase  incident 


Fig.  64. — Bransford  Lewis'  Induction 
Rheostat. 


136 


CYSTOSCOPY   AND    URETHROSCOPY 


to  regulation  by  successive  buttons.  The  security  against  shock 
or  grounded  current  is  attained  by  having  the  rheostat  composed 
of  two  separate  coils  of  wire,  one  within  the  other,  affording  an 
induced  current  from  one  to  the  other,  with  no  direct  connection 
between  them;  so  that  it  is  impossible  for  the  street  current  to 
be  transmitted  directly  to  the  operator  or  the  patient  when  this 
rheostat  is  in  use. 


Fig.  65.— The  Bransford  Lewis  electric  controller  (for  direct  or  alternating  current). 

This  rheostat  can  be  used  only  in  connection  with  the  alter- 
nating current.  If  the  direct  current  is  the  only  one  available 
a  motor  generator  may  be  interposed  to  develop  the  desired 
alternating  current,  which  is  then  led  into  the  rheostat.  All  of 
the  fulguration  or  high-frequency  apparatuses  on  the  market  that 
are  furnished  for  use  in  connection  with  the  direct  current  are 
supplied  with  such  a  motor  generator.     It  converts  the  direct 


OPERATWE    CYSTOSCOPY  137 

current  into  the  alternating  one;  and  the  current  so  supphed 
may  be  utihzed  with  the  rheostat  under  discussion,  affording 
the  safety  mentioned.  Under  these  circumstances  it  is  not 
necessary  to  provide  two  independent  sources  for  the  electricity 
used;  it  is  perfectly  safe  and  proper  to  use  the  one  source  (street 
current)  for  both  lighting  and  f ulguration  and  no  danger  of  short- 
circuiting  ensues. 

Another  controller  which  Mr.  Phillips  has  supplied  for  the 
author  is  one  shown  in  Fig.  65,  adapted  either  to  direct  or 
alternating  current,  and  furnishing  current  for  diagnostic  lamps, 
for  cauterization,  for  galvanism,  and  for  sinusoidalism.  A  pilot 
light  indicates  when  the  current  is  on  or  off.  The  controller  is 
made  either  as  a  wall  plate  or  table  plate.  It  has  long  been  diffi- 
cult to  obtain  a  controller  providing  both  cauterization  and  light- 
ing purposes  in  connection  with  both  direct  and  the  alternating 
currents;  and  the  convenience  of  this  arrangement  is  easily 
appreciated. 

Fulguration.  Cauterization  with  the  High-frequency  Cur- 
rent.— This  is  a  method  that  has  attracted  much  attention 
latterly  and  has  met  with  marked  favor  at  the  hands  of  a 
number  of  operators.  DeKeating-Hart  devised  the  plan  of 
applying  fulguration,  or  effective  cauterization,  by  means  of 
the  high  frequency  electric  current  to  warty  and  cancerous 
growths  on  various  parts  of  the  surface  of  the  body.  This 
was  found  to  be  very  successful  in  many  instances. 

To  Edwin  Beer,*  of  New  York,  must  be  given  the  credit  of 
planning  and  carrying  to  successful  issue  the  application  of  the 
same  principles  to  the  treatment  of  growths  within  the  bladder 
through  the  cystoscopy  The  outcome  has  proved  most  for- 
tunate. Upward  of  200  tumors  of  the  bladder  have  so  far  been 
reported!  as  having  been  treated  with  this  method,  the  several 
operators  being  highly  enthusiastic  in  the  praise  of  their  results. 

*  Beer,  Jour.  Am.  Med.  Assn.,  May  28,  19 10;  N.  Y.  Med.  Jour.,  Oct.  29,  19 10;  N.  Y. 
State  Jour,  of  Med.,  Sept.,  191 1. 

+  Beer,  Jour.  Am.  Med.  Assn.,  Nov.  16.  1912. 


138  CYSTOSCOPY   AND    URETHROSCOPY 

This  is  particularly  gratifying,  in  view  of  the  fact  that  methods 
of  treatment  for  vesical  neoplasms  hitherto  in  vogue  have  been 
uncertain  and  inadequate  in  a  large  proportion  of  cases.  This 
was  true  of  both  operative  and  non-operative  measures.  The 
percentage  of  recurrences  was  discouragingly  high,  even  in  cases 
that  were  deemed  benign  by  clinicians  and  pronounced  non- 
malignant  by  laboratory  findings.  Albarran  used  to  be  quoted 
as  saying,  "All  vesical  tumors  are  malignant  or  Hkely  to  become 
so." 

Beer  first  made  use  of  a  small  cable  of  copper  wires  held 
together  and  covered  by  insulating  material  resembling  that  of 
a  ureteral  catheter.  It  was  made  in  the  size  and  shape  of  a 
No.  5  or  6  ureteral  catheter,  with  the  wires  exposed  at  each  end. 
This  provided  for  connection  at  one  end  with  the  source  of  the 
current,  and  for  contact  in  the  bladder  with  the  tumor.  It  was 
found  unnecessary  to  provide  two  contacts  with  the  body  for  com- 
pleting the  electric  circuit,  as  with  the  galvanic  or  Faradic 
current,  and  that  mono-polar  contact,  as  with  ordinary  galvano- 
cauterization,  was  sufficient.  Later,  a  single  strand  of  steel  wire 
was  substituted  for  the  cable  of  copper  wires.  It  proved  more 
easily  handled  than  the  cable.  It  may  be  had  in  any  desired 
length  from  the  supply  houses. 

FULGURATION  APPARATUS 

A  number  of  high-frequency  apparatuses  have  been  placed 
on  the  market  to  meet  the  requirements  of  the  work.  The  list 
includes  several  so-called  portable  apparatuses.  As  a  matter 
of  fact,  it  requires  an  apparatus  of  considerable  power  to  effect 
destruction  or  decomposition  of  these  aggressive  growths,  and 
the  strength  of  the  current  delivered  is  therefore  of  much  impor- 
tance. Of  the  several  that  have  been  subjected  to  trial  by  the 
author  the  one  pictured  in  Fig.  66  has  proved  the  best  by  a 
considerable  margin.  It  delivers  a  powerful  current  whose 
immediate  effects  are  evident  in  the  bubbling  that  occurs  at  the 


OPERATIVE    CYSTOSCOPY 


139 


point  of  current  impact,  in  the  immediate  whitening  of  the 
tissues  there,  and  also  in  the  odor  of  burnt  flesh  that  soon  be- 
comes perceptible. 

More  important  still  is  the  after-effect  of  an  efficient  ap- 
paratus, as  compared  with  one  of  inferior  strength.  The 
involution  of  the  tumor  begins  more  promptly  and  is  carried  on 
more  rapidly  than  after  inefficient  fulguration.     Presumedly, 


Fig.  66. — The  Bransford  Lewis  Fulguration  apparatus  (Kny-Scheerer  Co.). 


the  ability  to  prevent  recurrence  is  also  greater  with  the  use  of 
the  better  apparatus. 

This  apparatus  is  built  on  the  interrupterless  transformer 
principle,  it  is  simple  of  adjustment  and  is  easy  of  application 
and  control.  Used  in  connection  with  the  alternating  current 
it  consists  of  a  high-tension  transformer,  the  secondary  of  which 
discharges  over  a  multiple  arm  spark  gap  and  loads  a  set  of 


140 


CYSTOSCOPY   AND    URETHROSCOPY 


high-frequency  condensers.     These  in  turn  discharge  through  a 
large  resonator  and  produce  the  following  varieties  of  currents: 

Auto-conduction, 

Auto-condensation, 

Thermo-penetration , 

Fulguration. 
A  d'Arsonval  current  can  be  delivered  up  to  any   desired 
amperage;  and  the  Oudin  current  is  such  as  described  above. 

When  a  direct  current  is  the  source  of  supply,  a  motor  is 
added  to  the  apparatus;  this  converts  the  current  into  the  re- 
quired alternating  variety.  In  either  case  the  make  and  break 
of  the  current  is  controlled  by  the  operator  by  means  of  a  foot 
switch. 

This  apparatus  is  manufactured  by  the  Kny-Scheerer  Co., 
of  New  York  City. 


Fig.  67. — Mode  of  applying  fulguration  to  papilloma  by  direct  method. 

Method  of  Application.— With  the  patient  in  the  usual  posi- 
tion for  cystoscopy  (Fig.  19)  and  the  usual  technique  of  clean- 
liness, irrigation  and  anesthesia  having  been  carried  out,  the 
cystoscope  is  introduced  and  the  tumor  located,  the  catheteriz- 
ing  telescope  carrying  the  wire  electrode  serving  for  this  purpose. 
When  brought  within  range,  the  electrode  is  pushed  through  its 


OPERATWE    CYSTOSCOPY 


141 


channel  until  it  comes  into  view  in  the  bladder.  A  little  further 
manipulation  brings  it  into  contact  with  the  side  or  pedicle  of 
the  tumor,  where  it  is  held  during  the  process  of  cauterization. 

Sometimes  the  direct  telescope  is  preferable  for  controlling 
the  direction  and  placing  of  the  electrode,  sometimes  the  indi- 
rect, according  to  the  location  of  the  tumor  (Figs.  67  and  68). 
If  attached  to  the  posterior  wall  or  base  of  the  bladder  the  growth 
may  be  reached  more  readily  through  the  direct  telescope; 
whereas,  if  attached  to  the  anterior  or  lateral  walls  or  the  apex, 
the  indirect  telescope  serves  much  better.     On  this  point  Beer* 


Fig.  68. — Mode  of  applying  fulguration  by  indirect  method. 

expresses  a  similar  conclusion,  and  regards  an  instrument  fur- 
nishing both  direct  and  indirect  modes  of  control  as  essential. 
He  says:  "Of  late  I  have  used  the  Bransford  Lewis  cystoscope, 
as  it  allows  of  direct  and  indirect  vision  applications  at  one  sit- 
ting without  withdrawing  the  instrument."  Water  is  univer- 
sally used  as  a  distending  medium  and  interferes  not  at  all  with 
the  effectiveness  of  the  fulguration. 

Having  brought  the  exposed  end  of  the  electrode  in  contact 
with  the  growth,  as  previously  described,  the  operator  turns  on 
the  current  by  means  of  a  foot  switch  conveniently  located  on 

*  Beer,  Annals  of  Surgery,  August,  1911;  New  York  State  Jour,  of  ]Med.,  Sept., 


142  CYSTOSCOPY   AND   URETHROSCOPY 

the  floor.  The  duration  of  the  application  is  timed  by  an  assist- 
ant. The  operator  watches  the  effect  of  the  application  through 
the  cystoscope.  Formerly  short  flashes,  of  ten  or  fifteen  seconds 
time,  were  made  use  of;  but  latterly  operators  have  prolonged 
this  to  forty  or  fifty  or  more  seconds,  at  the  same  time  diminish- 
ing the  intensity  of  the  current  by  shortening  the  spark  in  the 
muffler. 

Similar  applications  are  successively  made  to  other  areas 
of  the  tumor,  particularly  to  pedicle  or  base,  and  to  any  other 
tumors,  if  more  than  one  are  present;  after  which  it  is  well  to 
complete  the  seance  with  a  prophylactic  irrigation  (without 
catheter)  of  some  mild  antiseptic  fluid.  It  is  usually  advisable 
for  the  patient  to  keep  moderately  quiet  for  the  remainder  of 
the  day  after  such  treatment,  especially  if  there  is  any  tendency 
to  urinary  chills  or  fever;  otherwise,  he  may  be  about,  as  usual. 
The  treatment  may  be  repeated  at  intervals  of  four  or  five  days, 
the  length  of  time  being  determined  by  the  reaction  obtained 
from  the  instrumentation  rather  than  the  direct  effect  of  the 
fulguration. 

At  each  successive  seance  the  marked  influence  of  the 
previous  treatment  becomes  evident,  both  in  the  diminution  in 
size  of  the  growth  and  in  the  blanching  and  necrotic  changes 
apparent  on  its  surface.  These  have  been  noted  by  all  observers, 
and  they  furnish  evidence  of  the  favorable  influence  being  ex- 
erted on  the  neoplasm  (see  Figs.  69  and  70). 

For  the  purpose  of  securing  late  reports  of  the  results  ob- 
tained in  various  quarters,  Beer  wrote,  in  19 12,  to  all  surgeons 
who  he  thought  might  be  using  the  treatment.  He  reports 
(Jour,  of  Am.  Med.  Assn.,  Nov.  16,  19 12)  having  received  a 
large  number  of  replies.  Almost  aU  were  enthusiastically  favor- 
able to  the  new  method.  One  or  two  answers  were  favorable 
but  not  particularly  enthusiastic.  One  answer  was  far  from 
favorable,  but  in  view  of  the  fact  that  the  surgeon  in  question 
had  never  used  the  method,  his  comment  was  not  considered  of 
much  moment.     These  opinions  were  based  on  more  than  two 


Fig.  69. — Benign  papilloma.  Appearance  Feb.  5,  1913.  The  continuous  stream 
of  blood  shown  made  marked  hematuria  for  more  than  a  month  previously.  Left 
ureteral  orifice  in  view.     Case  of  author. 


Fig.  70. — Same  as  Fig.  69.     March  5,  after  five  fulgurations  had  been  given.      Bleeding 
ceased  after  second  treatment. 


Fig.  71. — Same  as  Fig.  70.  Appearance  April  4,  after  eight  fulgurations  had  been 
given.  A  depression  indicated  the  former  location  of  the  tumor.  Vesical  mucosa 
normal.     Arrow  indicates  site  of  healed  tumor. 


OPERATIVE    CYSTOSCOPY  I43 

hundred  cases  treated  by  this  method  in  the  United  States,  up 
to  the  time  of  the  making  of  the  report. 

While,  in  his  earHer  writings,  the  author  portrayed  hopes 
of  obtaining  success  with  the  method  in  early  cases  of  malignant 
growth,  in  this  later  report  he  expresses  his  conviction  that  no 
malignant  growth  will  be  cured  by  it. 

In  this  connection,  the  result  so  far  obtained  by  Keyes 
(Siirgery,  Gynecology  and  Obstetrics,  Jan.,  19 13)  in  a  case  of 
vesical  carcinoma  is  interesting.  In  mentioning  the  weU 
substantiated  fact  that  carcinomata  have  proved  amenable  to 
treatment  by  the  curette  and  by  arsenic  pastes,  in  certain  in- 
stances, and  by  radium  and  X-rays,  in  others,  when  in  accessible 
situations,  he  calls  attention  to  the  lately  developed  fact  that  the 
bladder  has  been  made  accessible  by  means  of  the  cystoscope, 
at  least  for  cauterization  methods  of  treatment;  and  that  it  is 
not  outside  of  the  bounds  of  possibility  to  obtain  success  with 
them  (as  embodied  in  the  Oudin  current,  plan  of  Beer)  in  early 
carcinoma.  At  any  rate,  he  reports  the  interesting  details  of  a 
case  under  his  observation  from  July,  1909,  to  December,  191 1, 
and  sums  up  as  follows:  ''A  small  papillary  growth  was  removed 
from  the  bladder  and  proved  carcinomatous  by  pathological 
examination.  It  recurred,  as  was  to  be  expected,  but  was 
apparently  cured  by  four  burns  with  the  d'Arsonval  current, 
and  is  known  not  to  have  relapsed  from  April  23,  1910,  to  Oc- 
tober 26,  1911. 

"in  the  meanwhile,  four  other  growths  of  similar  character 
appeared.  These  were  all  burned  with  the  Oudin  current.  Two 
of  them  were  cured  by  a  single  burn  on  May  14,  1910,  one  by 
two  burns,  in  January,  191 1,  and  the  cures  were  cystoscopicaUy 
verified  on  October  26,  191 1.  The  fifth  tumor  was  burned  four 
times  and  the  patient  was  not  cystoscoped  after  the  last  burn. 

"  Thus  we  have  a  known  carcinoma  apparently  cured  for 
eighteen  months,  two  recurrences  in  other  parts  of  the  bladder 
cured  seventeen  months,  one  cured  nine  months,  and  one  of 
which  the  cure  was  not  verified."     The  author  deems  this  clear 


144  CYSTOSCOPY   AND    URETHROSCOPY 

evidence,  at  least,  of  complete  control  of  a  small  carcinoma  for  a 
considerable  number  of  months. 

In  view  of  the  difficulty  of  determining . the  question  dis- 
cussed between  clinician  and  pathologist,  as  to  whether  a  given 
tumor  will  prove  malignant  or  benign  in  its  clinical  course,  and 
its  probable  amenability  to  fulguratiqn,  the  same  author  submits 
criteria  which  he  deems  more  serviceable  than  the  mere  report 
of  the  pathologist;  namely,  (a)  the  hardness  of  such  tumors; 
(b)  their  multiplicity  and  size;  (c)  sloughing  of  the  surface;  (d) 
intractable  cystitis. 

Hard  masses  are  more  resistent  to  burning  than  soft  ones. 
A  moderate  number  of  tumors  should  not  preclude  the  applica- 
tion of  the  method,  but  an  excessive  number,  together  with 
extensive  involvement,  would  be  factors  in  favor  of  the  operative 
rather  than  the  fulguration  method.  While  small  hemorrhagic 
and  sloughing  spots  do  not  necessarily  indicate  malignancy,  the 
author  has  never  yet  been  in  the  least  successful  in  burning  any 
tumor  covered  with  extensive  sloughing  areas.  Intractable 
cystitis  is  likewise  considered  a  condition  unfavorable  to  the 
success  of  cauterization.  It  is  therefore  proper,  in  such  cases, 
to  give  attention  to  this  factor  before  beginning  cauterization. 

Ureteral  Stricture.^ — The  ureter  is  not  infrequently  the  sub- 
ject of  subacute  or  chronic  infection  and  inflammation,  gonor- 
rheal, tuberculous,  etc.;  or  it  may  be  injured  by  the  passage  of  a 
stone  or  the  impaction  of  a  stone;  or  its  outlet  may  be  narrowed 
(Fig.  72)  by  pathological  processes  within  the  bladder — even- 
tuating in  the  production  of  cicatricial  stricture  of  that  organ  at 
some  point  or  points.  Ureteral  stricture  is  by  no  means  an 
uncommon  condition.  It  occurs  in  both  men  and  women,  more 
frequently  in  the  latter,  according  to  the  experience  of  the 
authors.  Its  capacity  for  injury  is  not  small.  By  narrowing 
the  passage  through  the  ureter  it  promotes  and  perpetuates 
inflammatory  processes  above  it,  either  in  the  ureter,  the  pelvis 
or  the  kidney,  w^hich  naturally  result  in  the  production  of  mucus 
and  pus.     Plugs  of  muco-pus  come  down  the  narrowed  channel 


OPERATIVE    CYSTOSCOPY 


145 


in  the  urine.  Occasionally  such  accumulations  or  plugs  fail  of 
passage  through  the  strictured  portion,  become  impacted  there, 
and  act  just  as  do  concretions  of  other  sorts  that  become 
impacted  in  the  ureter.  They  cause  ureteral  colic,  severe  pain, 
even  writhing  on  the  floor,  in  some  instances.     With  the  solution 


Dilated 
left  ureter 


Narrowing 

ureter 


Minute 

strictured 

orifice 


Fig.  72. — Dilated  ureter  due  to  stricture  near  vesical  end  of  ureter. 


or  the  passage  and  escape  of  the  plug  there  is  relief  from  the 
suffering,  and  the  patient  for  a  time  feels  as  well  as  usual,  only 
to  experience  a  recurrence  of  the  attack  with  the  engaging  of 
another  plug  in  the  strictured  part  of  the  canal.  The  injurious 
effects  are  not  limited  to  the  ones  mentioned — the  sufferings  of 


146  CYSTOSCOPY   AND   URETHROSCOPY 

the  patient — but  they  may  be  expended  on  the  kidney  itself, 
which  may  become  seriously  damaged  or  finally  destroyed  in  a 
manner  similar  to  that  in  which  a  kidney  undergoes  destruction 
from  an  impacted  calculus,  large  or  small,  in  the  ureter.  A 
female  patient  under  our  observation  had  been  incapacitated 
from  performing  even  the  ordinary  household  duties  for  more 
than  three  years  by  a  series  of  such  attacks,  but  was  promptly 
and  permanently  restored  to  health  and  comfort  when  a  definite 
stricture  was  recognized  at  the  lower  end  of  the  right  ureter  and 
sufficiently  dilated  to  permit  the  free  passage  of  the  urine  and 
its  contents.  In  this  case  it  was  difficult  at  first  to  gain 
entrance  for  even  the  smallest  ureteral  bougie  into  the  narrowed 
opening.  But  after  a  number  of  attempts,  with  repetitions  of 
the  pressure  of  the  bougies  against  the  orifice,  a  small  one  did 
effect  entrance  and  passed  up  the  ureter.  Successive  sizes  were 
then  introduced,  until  the  opening  was  large  enough  to  permit 
the  introduction  of  the  metal  ureteral  dilator  (3,  Fig.  58),  after 
which  success  was  assured. 

If  the  narrowing  be  located  immediately  at  the  orifice  it  may 
be  incised  with  the  ureteral  scissors  (2,  Fig.  58).  The  alligator 
forceps  may  be  used  also  as  a  dilator  when  the  stricture  is  at 
the  outlet,  but  its  angle  of  opening  is  too  abrupt  for  safe  use  far 
within  the  channel. 

A  styletted  silk-web  bougie,  insulated  except  at  the  end,  may 
be  provided  for  applying  electrolysis  against  a  stricture  higher 
up  in  the  ureter;  but  it  is  questionable  whether  it  would  be 
entirely  safe.  It  is  conceivable  that  the  electrolytic  action 
might  be  against  the  wall  of  the  ureter  instead  of  the  stricture, 
with  the  result  of  making  a  false  passage. 

Ureteral  stenosis  or  obstruction  may  be  caused  by  the  pres- 
sure of  a  tumor  or  growth  in  adjacent  structures,  or  by  the  con- 
traction of  adhesions  in  neighboring  tissues.  It  is  scarcely 
probable  that  any  lasting  benefit  can  come  from  intraureteral 
manipulations  under  such  circumstances.  Obstruction  of  the 
organ  from  kinks  or  bends  is  also  not  amenable  to  relief  by 


OPERATIVE    CYSTOSCOPY 


147 


this  means,  and  resort  must  be  had  to  repositing  the  kidney  or 
plastic  work  on  the  pelvis,  etc.  Obstruction  due  to  the  crossing 
of  the  ureter  by  an  anomalous  vessel  is  best  relieved  by  tying 
and  cutting  the  vessel. 

Ureteral  Calculus. — Much  may  be  done  by  cystoscopic  means 
to  assist  the  passage  of  a  stone  through  the  ureter,  so  that  the 
authors  are  not  in  sympathy  with  and  cannot  support  the 
unqualified  adoption  of  the  measures  customarily  applied  in  the 


Fig.  73. — Stone  in  orifice  of  left  ureter. 


presence  of  calculus  in  transit  or  impacted  in  the  ureter;  that  is^ 
the  placing  of  one's  faith  in  a  strictly  expectant  plan,  in  the 
belief  that  the  ureter  will  eventually  expel  the  intruder,  if  aided 
with  hot  applications  and  the  use  of  morphia,  as  strongly  urged 
by  some;  or  the  early  or  immediate  resort  to  laparotomy  and  the 
extraperitoneal  incision  into  the  ureter  for  the  direct  removal  of 
the  stone.  Since  it  is  an  indisputable  fact  that  ureteral  stones 
have  in  numerous  instances  been  removed  or  assisted  in  their 


148  CYSTOSCOPY   AND    URETHROSCOPY 

transit  and  expulsion  by  various  cystoscopic  measures  and  ma- 
neuvers, it  would  seem  beyond  all  argument  that  such  measures, 
innocuous  as  they  are,  should  have  a  definite  and  well-established 
position  in  the  esteem  of  the  profession,  under  such  circum- 
stances. But  such  is  not  the  case.  A  review  of  the  literature 
of  ureteral  calculus  of  the  past  few  years  shows  the  therapy  of 
the  subject  to  be  dominated  with  but  the  two  ideas,  the  expectant 


Fig.   74. — Removing  stone  from  orifice  of  left  ureter  by  means  of  alligator  forceps  used 
\  through  operating  cystoscope. 

plan^'or  the  major  surgical  one  of  abdominal  incision.  And 
therein  may  be  found,  as  well,  evidence  of  the  disastrous  outcome 
of  both  plans:  The  destruction  of  kidneys  from  too  prolonged 
reliance  being  placed  on  the  efficacy  of  the  former,  and  the  serious 
complications  that  have  followed,  in  certain  instances,  the  appli- 
cation of  the  latter  (dangerous  hemorrhage,  primary  or  second- 
ary, from  iliac  arteries,*  ureteral  leakage  from  fistula,  etc.). 

*  Moschowitz:  Annals  of  Surgery,  Dec,  1908. 


OPERATWE    CYSTOSCOPY  I49 

Allusion  to  the  efficacy  of  cystoscopic  measures  is  practically 
confined  to  contributions  of  reports  of  cases  successfully  handled 
in  this  way. 

It  cannot  be  claimed  that  this  is  either  just  or  fair  to  a  deserv- 
ing method  of  therapy.  It  is  neither  fair  to  the  profession  nor 
to  the  sufferers  from  such  conditions.  Whatever  possibility  of 
relief  it  embraces  should  be  made  known  to  both,  and  patients 
should  at  least  be  given  the  benefit  of  the  doubt — a  trial  of  cysto- 
scopic methods — before  being  subjected  to  major  surgical  pro- 
cedures, the  outcome  of  which  can  never  be  assured.  The 
cystoscopic  method,  if  it  fail,  wiU  leave  the  patient  in  no  worse 
condition  for  the  adoption  of  other  measures;  and  if  successful, 
affords  the  relief  without  entailing  a  more  or  less  dangerous  cut- 
ting operation  and  without  the  patient's  having  to  remain  in  bed 
for  any  length  of  time.  He  is  an  ambulatory  patient,  meantime, 
even  if  the  attempt  to  remove  the  stone  has  to  be  repeated  sev- 
eral times.  (See  "Removal  of  Ureteral  Stone  by  Cystoscopic 
Methods,"  by  Bransford  Lewis,  New  York  ]\Ied.  Jour.,  Nov. 
16,  1912.) 

Not  all  stones  are  impacted  at  the  same  point  in  the  ureter; 
not  all  stones  are  of  equal  dimensions;  and  not  all  stones  are 
equally  accessible  or  equally  amenable  to  the  cystoscopic  method 
of  removal.  The  three  points  of  natural  narrowing  of  the  ureter, 
are  the  locations  at  which  calculi  are  prone  to  hang;  that  is, 
within  an  inch  below  the  kidney  pelvis;  at  the  site  of  the  crossing! 
of  the  iliac  artery;  and  the  lower  ureteral  orifice  (Fig.  73)  on 
part  of  the  ureter  that  passes  obliquely  through  the  vesical  wall 
(intramural  portion).  j 

To  illustrate  the  manner  in  which  a  stone  may  hang  at  the 
lower  orifice  for  a  long  period,  apparently  ready  to  emerge,  yet 
failing  to  do  so,  and  then  prove  readily  amenable  to  cystoscopic 
removal,  the  following  case  may  be  cited: 

Dr.  W.  L.  Goddard,  practising  physician,  Saulsbury,  Tenn. ; 
first  consultation  Oct.  29,  1908.  History  of  repeated  attacks  of 
renal  colic  on  the  left  side,  dating  from  twelve  years  previously; 


150  CYSTOSCOPY   AND   URETHROSCOPY 

the  passage  of  a  small  stone  one  and  one-half  years  previously; 
and  the  existence,  during  the  past  nine  months,  of  an  unceasing 
dull  pain  in  the  left  inguinal  region,  never  absent  day  or  night  in 
the  waking  moments  of  the  patient.  Urine  perfectly  clear. 
Cystoscopy  easily  carried  out  at  the  first  interview  (universal 
cystoscope);  showed  the  bladder  and  the  right  ureteral  orifice 
normal;  within  the  orifice  of  the  left  ureter  a  little  dark-looking 
plug  appeared,  plainly  visible  to  both  direct  and  right-angle 
view.  The  universal  was  replaced  with  the  operative  cysto- 
scope, with  water  as  a  distending  medium.  The  alligator  for- 
ceps was  inserted  into  the  affected  opening,  the  plug  escaping 
and  passing  backward  along  the  channel  of  the  ureter.  The 
forceps  was  then  dilated  strongly,  opening  the  orifice  widely, 
and  then  withdrawn.  Immediately  the  little  plug  popped  out 
of  the  ureter,  plainly  under  the  observation  of  the  operator,  and 
was  followed  by  a  rush  of  pus  and  urine,  as  though  it  had  been 
pent  up  in  the  ureter.  Almost  immediately  afterward  Dr. 
Goddard,  the  patient,  remarked,  "That's  the  first  time  in  nine 
months  that  I  have  been  free  from  that  pain  in  the  lower  part  of 
the  abdomen."  And,  it  may  be  remarked,  he  has  never  felt  it 
since  that  time. 

Several  physicians  were  in  the  office  at  the  time,  and  observed 
the  plug  in  the  orifice  and  the  maneuvers  executed  in  its  removal ; 
and  also  saw  it  as  it  then  lay  in  the  bas  fond  of  the  bladder.  The 
patient  shortly  afterward  passed  it  out  by  natural  urination. 
If  this  had  not  occurred  it  would  have  been  an  easy  matter  to 
grasp  and  remove  it  with  the  forceps.  The  specimen  shows  a 
small  spicule  at  one  point.  This  spicule  had  caught  in  the 
lip  of  the  ureteral  orifice  and  had  been  the  means  of  prevent- 
ing the  expulsion  of  the  intruder.  It  might  have  remained 
indefinitely,  unless  removed  by  some  surgical  measure,  cysto- 
scopic  or  otherwise,  grown  larger  by  accretion,  and  gradually 
injured  or  destroyed  the  kidney  above  it,  through  backward 
pressure,  infection,  etc. 

The  patient  left  for  home  two  days  afterward,  feeling  per- 


OPERATWE    CYSTOSCOPY  15I 

fectly  well,  and  has  had  no  recurrence  of  the  trouble  since  (six 
years) . 

If  the  stone  be  located  higher  up  in  the  ureteral  channel  it 
may  not  be  possible  to  reach  it  or  remove  it  immediately,  and 
yet    it   is   not   necessarily  beyond   the  sphere  of  cystoscopic 


Fig.  75. — Stone  lodged  in  mid-ureter,  J.S.F. 

influence.  The  ureter  below  the  point  of  impaction  may  be 
stretched  or  dilated  by  the  passage  of  sounds  or  bougies,  or 
by  distending  it  with  fluids  or  oils,  injected  through  a  ureteral 
catheter;  all  of  which  tend  not  only  to  dislodge  the  stone  but 
to  lubricate  the  channel  and  facilitate  its  passage  downward, 


152 


CYSTOSCOPY   AND    URETHROSCOPY 


especially  if  assisted  by  the  drinking  of  considerable  quantities 
of  "water  for  the  vis  a  tergo  that  comes  in  the  elimination.  Once 
it  reaches  the  lower  end  of  the  ureter  or  its  immediate  neighbor- 
hood, the  metal  instruments  may  be  used:  The  dilator  for 
further  stretching  the  orifice,  if  necessary;  the  flexible  forceps 
for  efforts  at  grasping  the  stone  if  within  an  inch  or  two  of  the 
orifice,  or  the  alligator  forceps  if  nearer  the  outlet. 


Fig.  76. — Showing   cystoscope,    X-ray   catheter   and  stone   in   lower   end  of  ureter, 
after  descent  from  position  shown  in  Fig.  75. 

When  the  stone  has  been  brought  into  the  bladder  the  re- 
mainder of  the  problem  is  easy  of  solution:  It  is  picked  up 
with  the  alligator  forceps  and  removed  (Fig.  74).  If  it  be  too 
large  to  pass  through  the  sheath  of  the  cystoscope  it  may  be 
either  crushed  and  removed,  or  it  may  be  grasped  and  drawn  as 
far  as  possible  into  the  beak-end  of  the  sheath  in  which  it  is 


OPERATIVE    CYSTOSCOPY 


153 


held  while  sheath,  forceps  and  stone  are  drawn  out  coincidently. 
A  small  stone  will  usually  pass  from  the  bladder  in  voluntary 
urination,  only  it  is  liable  to  be  lost  unless  arrangements  are 
made  for  the  patient  to  urinate  into  a  vessel  covered  by  a  layer 
of  gauze  as  a  sieve. 

Patient,  J.  S.  F.,  age  44,  gave  history  of  fourteen  months 
standing;  renal  colics  on  right  side,  frequent,  severe  and  often 
requiring  the  h>podermic  use  of  morphine  for  relief.  Was 
under  "solvent"  treatment  for  about  a  year,  without  favorable 
result. 

On  coming  under  our  care,  a  radiograph  catheter  was  ob- 
structed at  about  four  inches  above  the  right  ureteral  orifice, 
and  X-ray  showed  a  stone,  together  with  the  catheter,  at  that 


Fig.  77. — Ureteral  stone  removed  from  J.  S.  F.;  actual  size. 


point  (see  Fig.  75).  The  catheter  was  moved  up  and  down, 
for  its  loosening  effect;  and  liquid  albolene  was  injected  on  two 
occasions.  Another  X-ray  taken  two  weeks  later  showed  that 
the  stone  had  descended  to  the  intra-mural  part  of  the  ureter 
(Fig.  76).  It  was  known  by  cystoscopy  that  the  orifice  of  this 
ureter  was  contracted  tightly,  presenting  an  effective  barrier 
to  the  escape  of  the  stone,  although  it  had  reached  this  low  posi- 
tion. Indeed,  a  small-sized  catheter  was  all  that  could  be 
introduced  into  the  orifice,  up  to  this  time.  Not  even  a  small 
metal  dilator  could  be  made  to  enter.  Through  the  operating 
cystoscope,  therefore,  one  blade  of  the  ureteral  scissors  was  in- 
serted into  the  orifice  and  an  incision  was  made  though  the 
dorsal  lip  for  a  half  inch  (Figs,  79  and  80).     On  the  following 


154  CYSTOSCOPY   AND    URETHROSCOPY 

day  the  patient  voluntarily  passed  the  stone  (Fig.  77)  and  was 
completely  relieved  thereafter.  He  gained  about  fifteen  pounds 
during  the  next  month;  and  has  had  no  recurrence  of  symptoms 
or  signs. 


Fig.  78. — Diagram  showing  strictured        Fig.  79. — Ureteral  scissors  cutting  stric- 
right  ureteral  orifice  retaining  a  stone.  tured  orifice  of  ureter. 


Fig.  80. — Orifice  widened  by  scissors  permits  escape  of  calculus. 


PART  II 
URETHROSCOPY 

CHAPTER  I 
ANATOMY  OF  THE  MALE  URETHRA 

The  urethra  is  the  passage  for  the  exit  of  urine  from  the  blad- 
der, and,  in  the  male,  for  the  emission  of  the  contents  of  the 
seminal  vesicles  and  prostate  gland. 

While  the  urethra  is  thus  a  canal  in  fact,  in  the  flaccid  state 
of  the  penis  it  is  a  canal  only  in  theory,  for  the  walls  are  in  com- 
plete apposition  throughout  its  extent,  except  when  they  may  be 
spread  apart  by  the  passage  of  urine  or  instruments.  The 
urethral  walls,  lying  in  apposition,  have,  upon  transverse  section, 
the  appearance  of  a  vertical  slit  in  the  region  of  the  glans;  in  the 
membranous,  a  stellate  appearance;  they  present  a  transverse 
slit  in  the  spongy  region  and  in  the  prostatic  region,  the  form  of 
an  inverted  Y. 

For  descriptive  purposes  the  urethra  is  divided  into  the 
prostatic  urethra,  about  one  and  one-quarter  inches  in  length, 
which  is  that  part  of  the  canal  surrounded  by  the  prostate  gland; 
the  membranous  urethra,  about  three-quarters  of  an  inch  in 
length,  which  extends  from  the  apex  of  the  prostate  to  the  bulb 
of  the  corpus  spongiosum;  and  the  spongy  urethra,  which  is 
enclosed  in  the  corpus  spongiosum  from  the  bulb  to  the  termina- 
tion of  the  canal  at  the  tip  of  the  glans — about  six  inches.  The 
spongy  urethra  is  still  further  subdivided  into  the  bulbo- perineal, 
scrotal,  penile  and  navicular  portions,  the  names  of  which  are 
sufficiently  descriptive. 

In  a  state  of  distention  the  form  of  the  canal  is  that  of  a 
cylinder  of  irregular  contour  and  size,  the  walls  having  a  varying 

155 


156  CYSTOSCOPY   AND   URETHROSCOPY 

degree  of  distensibility.  In  the  meatus  we  ordinarily  find  the 
lowest  distensibility  and  the  smallest  caliber,  often  not  more 
than  24  of  the  French  scale.  The  fossa  navicularis,  a  small 
flask-like  dilatation,  which  lies  just  inside  the  meatus,  quickly 
contracts  again  into  a  neck-like  narrowing,  often  less  in  caliber 
than  the  meatus  itself,  but  more  distensible.  The  spongy 
urethra  gradually  widens  in  the  form  of  an  elongated,  truncated 
cone  from  the  narrow  inlet  at  the  navicular  fossa,  to  its  maximum 
dimensions  at  the  bulb.  At  this  point  the  walls  of  the  urethra, 
especially  the  lower  or  posterior  wall,  are  very  distensible,  and, 
even  in  the  flaccid  state,  form  a  well-marked  dilatation  just 
anterior  to  the  cut-off  muscle,  the  bulbar  cul-de-sac  or  the  bulb. 
Then  the  canal  again  narrows,  at  the  point  where  it  pierces  the 
external  layer  of  the  triangular  ligament,  and  maintains  a  like 
diameter  throughout  the  whole  membranous  portion.  Upon 
passing  the  deep  layer  of  the  triangular  ligament  and  entering  the 
prostatic  portion,  the  urethra  takes  on  a  fusiform  shape,  becom- 
ing narrowed  at  the  vesical  neck,  and  there  enters  the  bladder. 
In  the  foregoing  description  we  have  taken,  not  the  course  of 
the  flow  of  the  urine,  but  the  one  of  the  passage  of  instruments 
through  the  urethra  into  the  bladder. 

The  urethra,  though  in  a  state  of  tonic  closure  having  the 
contour  as  described,  is  capable  of  a  great  and  varying  amount  of 
distention  in  its  different  segments,  by  virtue  of  the  elasticity 
of  the  urethral  walls.  In  general,  the  deeper  parts  are  the  more 
dilatable.  Thus,  while  the  meatus  may  exhibit  a  caliber  of  only 
24  French,  and  with  difficulty  be  dilated  to  receive  a  26  sound, 
the  spongy  portion  back  of  the  fossa  will  take  a  28  or  30,  and  the 
bulbous  urethra  up  to  40  or  higher.  The  canal  narrows  in  the 
membranous  portion,  the  site  of  the  cut-off  muscle,  but  in  this 
part  may  be  dilated  to  30  or  higher.  In  the  prostatic  region 
one  may,  without  inconvenience,  dilate  up  to  40  or  45. 

To  repeat,  the  points  of  constriction  in  the  male  urethra  are, 
first,  at  the  meatus;  second,  at  the  neck  of  the  fossa  navicularis; 
third,  at  the  cut-off  muscle,  and  fourth,  at  the  bladder  neck. 


THE  ANATOMY  OF  THE  MALE  URETHRA  157 

There  is  a  great  amount  of  variation  in  individuals  in  the  caliber 
and  the  amount  of  constriction  at  these  points;  but  the  general 
ratio  is,  in  the  absence  of  pathological  change,  practically  always 
preserved,  excepting  that  the  meatus  is  sometimes  found  to  be 
unduly  small,  compared  to  the  rest  of  the  urethra.  The 
cause  of  the  difference  in  distensibiUty  of  these  constrictions  may 
be  found  in  the  structure  of  the  peri-urethral  tissues  at  these 
points:  At  the  meatus,  the  urethra  being  imbedded  in  the 
glans  portion  of  the  corpus  spongiosum,  which  here  is  relatively 
compact,  restricts  the  elasticity  of  the  canal  wall.  This  is  true 
also,  though  to  a  less  extent,  at  the  deeper  inlet  of  the  fossa,  and 
all  along  the  spongy  portion  in  lessening  degree,  to  the  bulb; 
as  the  pars  spongiosum,  it  is  recalled,  lies  between  and  below 
the  corpora  cavernosa.  The  constriction  at  the  membranous 
portion  and  that  at  the  bladder  neck  are  purely  muscular  in 
character  and  are  much  more  accommodating  than  that  at  the 
meatus,  once  the  muscular  spasm  is  overcome. 

Though,  as  before  stated,  there  exists  a  marked  sagging  of 
the  floor  of  the  urethra  at  the  bulb,  the  roof  of  the  urethra  forms 
an  uninterrupted  curve  from  the  fossa  navicularis  to  the  bladder 
(when  the  penis  is  erect).  The  mucous  membrane  of  the  roof  is 
more  closely  adherent  than  that  of  the  floor,  and  is  less  elastic. 
These  facts  show  the  proper  wall  to  follow  in  the  passing  of  instru- 
ments to  be  the  anterior  or  roof.  Thus,  the  curve  of  the  urethra 
is  the  curve  of  the  roof  with  its  fixed  point  between  the  two 
layers  of  the  triangular  ligament.  Behind  this  point  the  direc- 
tion of  the  prostatic  urethra  is  up  and  back,  and  in  front  of  it 
the  bulb  takes  a  direction  forward  and  up  by  reason  of  the  ten- 
sion of  the  suspensory  ligament  of  the  penis.  This  forms  the 
so-called  fixed  curve  of  the  urethra,  though  the  parts  anterior 
and  posterior  to  the  two  layers  of  the  triangular  ligament  are 
not  fixed,  absolutely. 

Though  the  degree  of  curve  differs  in  individuals,  and  even  in 
the  same  person  at  different  ages,  the  one  which  will  accord  with 
the  greatest  number  of  urethrae  is  that  of  a  circle  8.125  cm.  in 


158  CYSTOSCOPY   AND   URETHROSCOPY 

diameter ;  and  the  proper  length  of  arc  of  such  a  circle  to  repre- 
sent the  suprapubic  curve,  is  that  subtended  by  a  cord  6.875 
centimeters  long  (Keyes). 

Histologically,  the  urethra  is  composed,  in  its  thickness,  of 
some  four  layers  of  tissue.  Lining  the  canal  is  the  epithelial 
layer,  which  differs  somewhat  in  the  morphology  of  the  cells 
in  the  several  parts  of  the  canal.  Just  inside  the  meatus  the 
cells  are  similar  to  the  other  mucous  orifices  of  the  body,  partak- 
ing of  the  nature  of  the  epidermis  in  their  stratified  squamous 
appearance,  merging  in  the  fossa  navicularis  into  the  stratified 
cylindric  type  which  prevails  until  the  epithelium  again  reverts 
to  the  squamous  type  in  the  upper  part  of  the  prostatic  urethra, 
where  it  merges  insensibly  into  that  of  the  bladder. 

The  urethral  epithelium  is  normally  smooth,  moist,  and 
shiny — showing  by  its  transparency  the  color  of  the  mucosa 
beneath. 

The  second  layer  constitutes  the  mucous  membrane.  Being 
continuous  anteriorly  with  that  of  the  glans  and  posteriorly  fused 
into  that  of  the  bladder,  it  extends  into  Cowper's  glands,  the 
ejaculatory  ducts,  the  seminal  vesicles,  the  vasa  deferentia,  and 
the  epididymis.  This  layer  is  very  elastic  and  is  intimately 
adherent  to  the  subjacent  layers,  particularly  on  the  roof  of  the 
spongy  portion,  and  in  the  prostate. 

Beneath  the  mucous  membrane  is  a  layer  of  thick,  smooth- 
fibered  musculature,  especially  thick  in  the  membranous  portion. 
This  coat  is  in  two  layers,  more  or  less  distinct.  The  inner  lies 
longitudinally,  while  the  outer  fibers  are  disposed  circularly. 
At  the  point  where  the  urethra  reaches  the  bladder  there  is  a 
distinct  thickening  of  the  circular  fibers,  forming  a  sphincter, 
the  internal  or  vesical  sphincter.  The  external  sphincter  is  formed 
in  the  following  manner :  In  all  of  the  neighborhood  of  the  bladder 
there  appears  a  third  layer  of  muscle  fibers  above  the  urethra, 
forming  a  sort  of  arciform  muscle,  held  between  the  prostatic 
lobes.  These  fibers  increase  in  number  in  passing  through  the 
prostate,  and,  where  the  urethra  pierces  the  deep  layer  of  the 


THE  ANATOMY  OF  THE  MALE  URETHRA  1 59 

triangular  ligament,  they  form  a  sphincter-like  ring  which  is 
continuous  with  the  muscles  of  the  hgament,  this  making  up 
the  cut-of  muscle. 

Anterior  to  the  superficial  layer  of  the  triangular  ligament 
lies  the  spongy  body,  the  corpus  spongiosum,  which  forms  the! 
fourth  or  erectile  layer  of  that  part  of  the  male  urethra.  It 
begins  in  a  bulbous  enlargement  which  is  fixed  to  the  lower  part 
and  between  the  corpora  cavernosa  of  the  shaft  by  the  hulho 
cavernosus  muscle,  and  ends  in  a  dilated  extremity,  the  glans 
penis. 

The  internal  surface  of  the  male  urethra,  excepting  when  in  a 
state  of  complete  tension,  forms  a  series  of  longitudinal  folds, 
more  or  less  numerous  and  of  varying  size.  There  are  also 
certain  folds  disposed  transversely  to  permit  of  extension  during 
erection.  These  folds,  and  the  intervening  sulci  present  a  large 
number  of  orifices  of  small  glands  and  culs-de-sac,  as  well  as 
papillcB,  these  latter  being  more  numerous  in  the  fossa 
navicularis. 

The  culs-de-sac  {Morgagni's  lacunce)  penetrate  obliquely 
from  before  back  and  up,  in  the  mucous  membrane  of  the  roof 
of  the  spongy  region.  The  largest  of  these  culs-de-sac  is  the 
lacuna  magna,  found  on  the  roof  of  the  fossa  navicularis,  just 
inside  the  meatus.  For  the  most  part,  Morgagni's  lacunae  are 
of  a  size  to  hardly  admit  the  head  of  a  pin.  There  are  from  six 
to  ten  of  them  and  they  are  found  along  the  median  line.  Owing 
to  the  oblique  direction  of  the  sac,  backward  and  up,  the  upper 
wall  forms  a  sort  of  valve,  the  one  at  the  site  of  the  lacuna  magna 
being  known  as  the  valve  of  Guerin. 

The  importance  of  the  amount  of  obstruction  which  these 
culs-de-sac  oppose  to  instrumentation  has  been  greatly  exag- 
gerated. Using  an  instrument  with  a  tip  the  size  of  that  of  an 
ordinary  sound,  they  need  not  be  considered. 

In  largest  number  are  found  the  glands  of  Littre.  Most 
abundant  upon  the  roof  of  the  spongy  portion,  where  their 
orifices  form  a  close  dotting,  they  are  also  found  in  large  number 


l6o  CYSTOSCOPY   AND   URETHROSCOPY 

throughout  all  portions  of  the  urethra — though  in  the  posterior 
urethra  the  gland  bodies  are  rudimentary. 

The  depth  at  which  the  bodies  of  the  glands  of  Littre  lie 
varies.  Though  for  the  most  part  they  lie  just  beneath  the 
epithelium,  they  may  be  also  found  deep  in  the  sub  mucosa 
and  even  in  the  erectile  tissue.  The  length  of  the  excretory 
ducts,  therefore,  also  varies  greatly.  These  ducts,  in  general, 
run  in  an  oblique  direction  from  the  gland  toward  the  meatus, 
opening  either  upon  the  surface  of  the  mucous  membrane,  or 
into  the  cavities  of  Morgagni's  lacunae.  Littre's  are  mucous- 
secreting,  conglomerate  glands. 

Cowper^s  glands  are  tw^o  small,  lobulated  bodies  the  size  of 
cherry  stones,  lying  beneath  the  fore  part  of  the  membranous 
urethra,  between  the  two  layers  of  the  triangular  ligament. 
They  lie  close  behind  the  bulb  and  are  enclosed  by  the  com- 
pressor urethra  muscle.  The  lobules  are  composed  of  a  number 
of  acini,  lined  by  columnar  epithelium,  which  open  into  a  com- 
mon duct.  These  ducts  are  about  1.5  centimeters  long  and  pass 
obliquely  forward  beneath  the  mucous  membrane,  opening  upon 
the  floor  of  the  bulbous  urethra  by  two  very  small  orifices,  lying 
side  by  side. 

The  prostatic  follicles  lie  in  the  substance  of  the  prostate  gland 
between  inner  and  outer  layers  of  muscle  tissue;  being  particu- 
larly numerous  in  that  part  of  the  prostate  lying  posterior  to 
the  urethra.  These  follicles  open  into  elongated  canals  which 
join  to  form  from  ten  to  twenty  small  excretory  ducts  which  open 
into  the  floor  of  the  prostatic  urethra  on  either  side  of  the 
verumontanum.  Both  follicles  and  ducts  are  lined  by  columnar 
epithelium. 

The  mucous  membrane  in  the  prostatic  portion  presents  a 
fold  or  reduplication  lying  antero-posteriorly  in  the  middle  line 
of  the  floor,  traceable  from  the  external  angles  of  the  bladder 
trigone.  This  forms  a  considerable  eminence  which  is  variously 
known  as  the  verumontanum,  caput  gallinaginis  and  colliculus 
seminalis.     To  the  right  and  left  of  this  eminence  are  two  small 


THE  ANATOMY  OF  THE  MALE  URETHRA  l6l 

slits,  marking  the  openings  of  the  ejaculatory  ducts.  In  the 
center,  anteriorly,  is  a  small  depression,  the  prostatic  utricle  or 
uterus  masculinus,  which  extends  upward  and  back  a  distance 
of  0,5  centimeter  into  the  substance  of  the  prostate  gland 
beneath  the  middle  lobe. 


CHAPTER  II 
DEVELOPMENT    OF   THE    URETHROSCOPE 

The  development  of  the  urethroscope  is  so  intimately  asso- 
ciated with  that  of  the  cystoscope,  that  a  review  of  its  history  in 
detail  from  the  time  of  its  conception  by  Bozzini,  of  Frankfort, 
in  1806,  up  to  the  presentation  to  the  profession  of  his  endoscope 
by  Desormeaux,  of  Paris,  in  1853,  would  be  merely  a  repetition. 

In  this  interval  it  suffices  to  mention  the  work  of  Segalas,  of 
Strasburg,  in  1826,  of  Fisher,  of  Boston,  in  1827,  of  John  Avery, 
of  London,  in  1843,  of  M.  Cazenave,  of  Paris,  in  1848  and  the 
contemporary  work  of  Haken,  and  Bombalgini,  in  1853.  Desor- 
meaux  following  the  lines  laid  down  by  Fisher  produced  his 
endoscope.  His  was,  in  reality,  the  first  work  along  these  lines 
that  received  any  scientific  recognition.  For  his  endeavors  in 
this  direction  he  received  a  portion  of  the  Argenteuil  prize  in 
Paris,  in  1853.  In  1865  Doctor,  afterward  Sir  Francis  Richard 
Cruise,  succeeded  in  improving  the  illuminating  lamp  to  such  a 
degree  as  to  give  a  decided  impetus  to  endoscopy,  but  the  great 
degree  of  heat  generated  proved  a  serious  drawback  to  the 
instrument.  Efforts  were  made  to  provide  a  satisfactory  cool- 
ing apparatus  without  marked  success. 

In  urethroscopy,  as  in  cystoscopy,  the  advance  was  slow.  It 
was  not  until  1874  that  Griinfeld,  of  Vienna,  acting  on  the  prin- 
ciple suggested  by  Haken  in  1862  gave  to  the  profession  a 
urethral  endoscope  which  was  practicable.  The  tubes  were 
made  of  hard  rubber  with  a  bell-shaped  proximal  end.  The  light 
was  reflected  into  the  urethroscope  from  an  independent 
source  of  illumination  by  means  of  a  head  mirror.  Up  to  this 
time  all  attempts  at  urethroscopy  had  been  isolated  and  sporadic 
and  the  results  achieved  were  not  productive  of  enthusiasm,  but 

162 


DEVELOPMENT  OF  THE  URETHROSCOPE  1 63 

following  closely  Griinf eld's  achievement  the  results  were  pro- 
portionately rapid. 

To  Dr.  Max  Nitze,  of  Berlin,  must  be  accorded  the  credit  for 
the  distinct  advance  over  the  old  t>pe  of  instruments  which 
made  modern  urethroscopy  possible — the  placing  of  the  source 
of  light  in  the  instrument  near  the  field  to  be  examined.  Work- 
ing in  combination  with  Leiter,  of  Vienna,  he  produced  a  ureth- 
roscope in  which  the  source  of  light  was  an  incandescent  loop 
of  platinum  wire  placed  near  the  distal  end  of  the  urethroscope. 
Oberlander,  of  Dresden,  acting  on  this  principle  and  with  the 
assistance  of  Heynemann,  an  instrument  maker  of  Leipsic, 
produced  the  Nitze-Oberlander  instrument,  a  step  which  proved 
creative  of  modern  urethroscopy.  While  this  instrument  was  a 
great  improvement  on  former  urethroscopes,  it  was,  as  compared 
with  those  of  the  present  day,  crude  in  the  extreme. 

The  source  of  light  in  the  Nitze-Oberlander  instrument  was 
an  unprotected  platinum  loop  heated  to  incandescence  by  an 
electric  current.  The  great  heat  generated  necessitated  the 
attachment  to  the  instrument  of  an  apparatus  by  means  of  which 
a  constant  flow  of  cold  water  could  be  kept  circulating  in  the 
hollow  plane  upon  which  the  wire  rested.  This  rendered  the 
instrument  complex  and  cumbersome  and  the  unprotected  incan- 
descent loop  made  it  necessary  that  the  current  should  be  turned 
off  each  time  before  the  cotton  swabs  used  in  mopping  up  secre- 
tions and  making  applications  could  be  used.  These  objections 
necessarily  detracted  much  from  the  value  of  the  instrument. 

Following  closely  upon  the  work  of  Griinfeld,  Nitze,  Ober- 
lander, Antal,  Schutze,  Casper,  Leiter  and  Otis  produced  instru- 
ments for  the  purpose  of  examining  and  treating  the  urethra  and 
with  the  interest  thus  aroused  by  placing  urethroscopy  upon  the 
plane  of  practicability,  much  work  of  a  definite  character  resulted. 

To  overcome  the  objectionable  features  of  the  exposed  plati- 
num loop,  Loewenhardt,  of  Breslau,  invented  a  small  incandes- 
cent lamp  to  take  its  place,  but  it,  too,  proved  productive  of  so 
much  heat  that  it  was  impossible  to  put  it  to  practical  use  with- 


164  CYSTOSCOPY   AND   URETHROSCOPY 

out  the  addition  of  a  cooling  apparatus.  The  final  and  crowning 
step  in  urethroscopy,  the  advent  of  the  low  amperage  mignon 
lamp  with  a  minimum  of  heat  production,  must  be  credited  to 
America.  We  believe  that  this  achievement  is  due  to  the  sug- 
gestions of  Valentine,  of  New  York,  and  carried  out  by  Preston, 
an  electrician  of  Rochester,  though  credit  has  erroneously  been 
given  to  Dr.  Koch,  of  Rochester,  and  the  instrument  produced  at 
that  time,  1899,  bears  his  name.  In  this  instrument  the  light 
carrier  was  sheathed  in  an  auxiliary  tube  placed  on  the  floor  of 
the  endoscopic  tube.  While  the  urethroscope  taken  as  a  whole 
was  a  marked  improvement  over  those  formerly  in  use,  still  the 
projection  formed  by  the  auxiliary  tube  made  it  awkward  of 
insertion  and  productive  of  discomfort  to  the  patient.  A  urethra 
which  would  readily  admit  a  No.  30  sound,  Charriere  scale,  would 
hardly  permit  the  introduction  of  a  No.  26  urethroscope  on  the 
same  scale,  while  the  actual  lumen  of  the  urethroscope  was 
considerably  less. 

At  the  present  time  the-re  are  four  distinct  types  of  urethro- 
scopes :  those  which  have  the  source  of  illumination  in  the  form 
of  a  cold  lamp  within  the  tube,  those  which  have  the  light  pro- 
jected into  the  tube  from  without,  those  to  which  the  air-infla- 
tion principle  has  been  applied  and  those  having  a  lens-system 
similar  to  that  used  in  the  modern  type  of  cystoscope  and 
employing  water  distention  of  the  urethra.  The  Chetwood, 
Valentine,  and  Guiteras  instruments  are  the  best  representatives 
of  those  having  the  source  of  illumination  within  the  tube.  The 
Otis  urethroscope  is  by  far  the  most  satisfactory  instrument 
having  the  source  of  light  outside  the  tube.  The  replacing  of  the 
petroleum  lamp  by  the  incandescent  lamp  for  the  purpose  of 
illumination  in  the  reflecting  light  instrument  is  due  to  the  efforts 
of  Schall. 

The  use  of  air-inflation  in  connection  with  urethroscopy 
must  be  credited  to  Dr.  Geza  Von  Antal,  of  Buda-Pesth,  in  1887. 
He  applied  the  air-inflation  principle  to  an  instrument  of  the 
Griinfeld  type. 


DEVELOPMENT   OF   THE   URETHROSCOPE  165 

In  1890,  Dr.  Frank  Hewell,  Jr.,  of  New  York,  being  appar- 
ently without  any  knowledge  of  the  work  of  Antal,  suggested  the 
use  of  air-inflation  in  urethroscopy.  Later,  Mr.  E.  Hurry  Fen- 
wick,  of  London,  modified  Leiter's  instrument  for  the  purpose  of 
making  use  of  the  air-inflation  principle.  The  Fenwick  instru- 
ment, which  has  in  the  past  had  its  supporters  among  those 
who  preferred  the  air-inflation  t^'pe  of  urethroscope,  has  failed 
of  greater  acceptance  by  reason  of  the  fact  that  the  source  of 
light  was  outside  the  tube  and  the  instrument,  as  a  whole,  was 
cumbersome. 

On  December  19,  1903,  we  presented  in  the  Journal  of  the 
American  Medical  Association  a  new  type  of  air-inflation  ure- 
throscope. This  instrument,  slightly  modified,  was  later  pre- 
sented at  the  meeting  of  the  American  Urological  Association 
held  in  Atlantic  City  in  June,  1904.  We  have  since  made  a 
number  of  changes  in  the  instrument  and,  as  it  stands  to-day,  we 
believe  that  we  have  obviated  the  objectionable  features  of  the 
Fenwick  instrument  and  still  retain  its  advantages.  The  endo- 
scopic tube  conforms  to  the  general  lines  of  the  Guiteras  tube  and 
is  fitted  at  its  proximal  end  with  a  pin  projection  to  which  the 
light  carrier  is  readily  attached.  The  universal  head,  which  is 
attachable  to  any  size  tube  by  threads,  contains  the  valve  for  the 
attachment  of  the  inflating  bulbs  and  in  its  handle  contains  a 
spring  contact  for  connection  with  the  light  carrier.  An  ocular 
window  fits  the  universal  head  by  a  bevel  joint,  thus  making  it 
readily  attachable  to  and  detachable  from  the  instrument. 
The  instrument  permits  of  ease  in  assembling,  is  thoroughly  air- 
tight and  is  devoid  of  cumbersome  and  complex  features. 

Following  the  ideas  of  Kollmann,  we  have  had  certain  instru- 
ments constructed  for  intraurethral  work.  These  instruments 
comprise  knives,  forceps,  canulae,  probes,  scissors  and  cautery. 
These  instruments  may  be  used  through  the  operating  window 
which  is  fitted  with  a  metal  adjustable  gland,  to  which  is  attached 
a  rubber  nipple  assuring  an  air-tight  contact  and  yet  allowing 
perfect  mobility  on  the  part  of  the  operating  instrument. 


i66 


CYSTOSCOPY   AND    URETHROSCOPY 


In  the  early  part  of  1907,  Dr.  George  Walker,  of  Baltimore, 
devised  a  lens-system  urethroscope  having  a  lateral  opening  for 
use  with  water  distention  of  the  urethra.     This  instrument  was 


Fig.  81. — The  Ernest  G.  Mark  Aero-urethroscope.  A,  Swinburne  type  of  posterior 
tube  with  obturator  in  place;  B,  obturator;  C,  long  tube  for  antero-posterior  urethro- 
scopy; D,  window;  E,  short  anterior  tube  completely  asssembled;  F,  catheter  carrier 
for  catheterizing  the  ureter  in  the  female,  G,  H,  knives  for  intraurethral  operations; 
I,  gold  canula  for  injecting  the  ejaculatory  and  prostatic  ducts  or  infected  glandular 
openings  in  the  anterior  urethra;  /,  galvanocautery;  K,  probe;  L,  syringe  for  attach- 
ment to  canula.  ^ 


presented  to  the  profession  May  18,  1907,  in  the  Journal  of  the 
American  Medical  Association.  The  instrument  was  for  diag- 
nostic purposes  only.     In  June,  1907,  Dr.  Hans  Goldschmidt, 


DEVELOPMENT  OF  THE  URETHROSCOPE  167 

Utilizing  the  principle  of  the  Nitze  cystoscope,  devised  a  water 
distention  urethroscope  somewhat  on  the  principle  of  the  Walker 
urethroscope  but  employing  in  addition  a  curved  tube  for  obser- 
vation of  the  posterior  urethra.  This  instrument  is  also  fitted 
with  an  irrigating  attachment. 

In  19 10,  Dr.  Leo  Buerger,  of  New  York,  devised  and  pre- 
sented to  the  profession  a  urethroscope  employing  water  disten- 
tion which  is  exceedingly  ingenious. 

Within  the  past  year  McCarthy,  of  New  York,  has  developed 
a  close- vision  lens  urethroscope  which  gives  a  superior  view  of 
the  posterior  part  of  the  urethra  and  neck  of  the  bladder.  The 
extension  of  the  beak  of  other  such  instruments  has  been 
removed,  leaving  this  instrument  a  straight  one,  with  only  the 
suggestion  of  a  beak  in  the  shape  of  a  pointed  upturned  tip. 
This  gives  the  advantages  of  a  straight  instrument  for  turning, 
and  of  ease  of  introduction. 

For  the  purposes  of  treatment  we  consider  urethroscopes 
employing  water  distention  as  having  less  practical  value  than 
those  used  with  air. 

The  operator's  preference  for  any  particular  type  of  urethro- 
scope must  be  the  result  of  his  urethroscopic  work  with 
various  instruments.  Whatever  his  preference,  the  instru- 
ment must  fulfill  certain  requirements.  It  must  not  be  intricate 
or  cumbersome.  It  must  be  readily  sterilizable.  It  must  give 
for  its  outside  caliber  the  best  possible  urethroscopic  view.  It 
must  permit  of  ease  in  manipulation  on  the  part  of  the  operator 
with  the  least  possible  discomfort  to  the  patient.  These  points 
are  essential. 

For  satisfactory  urethroscopic  examinations,  the  following 
tubes  are  necessary:  Nos.  22,  24,  26,  28  and  30,  French,  in 
both  the  short  anterior  and  long  posterior  tubes.  In  a  series 
of  three  hundred  measurements  made  by  Kollmann  and  Ober- 
lander,  it  was  found  that  about  2  per  cent,  would  not  admit  of 
the  use  of  a  No.  23.  In  10  per  cent.,  it  was  necessary  to  use  a 
No.  23  while  25  per  cent,  required  a  No.  25.     In  the  remaining 


l68  CYSTOSCOPY   AND   URETHROSCOPY 

63  per  cent,  Nos.  27  and  29  were  available.  On  one  patient 
alone  could  a  No.  31  be  used. 

As  a  result  of  these  studies,  Oberlander  pointed  out  to  the 
profession  the  fallacy  in  the  use  of  the  tubes  of  small  size  which 
were  then  employed.  The  advantages  in  the  employment  of 
the  tubes  of  larger  caliber  are  obvious. 

The  source  of  electric  current  used  for  lighting  the  small 
incandescent  lamps  is  in  most  instances  a  matter  of  personal 
preference.  There  are  at  present  obtainable  many  excellent 
rheostats  for  attachment  to  the  lamp-sockets  of  the  dynamo- 
generated  current,  and  for  office  and  hospital  uses  this  method 
is  unquestionably  superior  to  the  current  obtained  from  a  dry- 
or  wet-cell  battery  on  account  of  the  gradual  loss  of  power  in 
the  latter.  There  is,  however,  one  precaution  in  the  use  of  the 
dynamo-generated  current  whose  observance  is  essential.  If 
the  floor  of  the  operating  room  be  of  concrete,  stone  or  tile,  the 
current  is  liable  to  become  grounded  through  the  operator  or 
patient  if  the  floor  be  damp.  Where  the  direct  current  is  used 
this  grounding  is  unaccompanied  by  danger  but  with  the  alter- 
nating current,  the  shock  may  be  fairly  severe.  Even  the  slight- 
est shock  to  a  patient  who  is,  as  a  rule,  laboring  under  a  certain 
amount  of  mental  stress,  is  hardly  conducive  to  a  satisfactory 
examination.  We  obviate  the  possibility  of  such  grounding 
of  the  circuit  by  using  a  rubber  castered  table  and  by  wearing 
either  rubber  gloves  or  rubber  overshoes.  The  use  of  the  in- 
duced current  rheostat  as  described  on  page  135,  will  obviate 
all  danger  of  grounding  of  the  current. 

Care  and  Sterilization  of  Instruments. — After  each  urethro- 
scopic  examination  the  tube  and  obturator  should  be  sterilized 
by  boiling — the  most  dependable  method.  They  should  be 
dried  out  of  boiling  water  to  prevent  rusting. 

The  light  carrier  cannot  be  boiled  and  must  be  washed  off 
thoroughly  with  liquid  soap  and  dried  out  of  alcohol.  This 
method  is  efficacious,  though  the  late  Dr.  Wm.  K.  Otis  insisted 
upon  the  necessity  of  using  nothing  in  or  through  the  tube 


DEVELOPMENT  OF  THE  URETHROSCOPE  1 69 

which  could  not  be  boiled,  and  for  that  reason  advocated  the 
use  of  the  urethroscopes  in  which  the  source  of  light  was  outside 
the  tube. 

The  light  carrier  is  replaced  in  the  tube  and  the  obturator 
inserted,  effectually  plugging  both  ends  of  the  tube. 

Subsequently  the  urethroscope  may  be  hung  in  a  glass  jar 
in  the  bottom  of  which  is  placed  formalin  pastiles.  To  prevent 
the  deposit  of  moisture  on  the  instruments,  which  tends  to  rust 
them,  a  few  crystals  of  calcium  chloride  may  be  suspended  in  the 
jar  wrapped  in  gauze. 

Personally,  we  do  not  see  the  necessity  of  placing  the  '.instru- 
ments in  formalin  vapor  after  the  tube  has  been  boiled  and  the 
light  carrier  thoroughly  cleansed.  If  the  urethroscope,  so  cleansed 
and  put  away  in  the  boxes  used  for  such  outfits,  is,  previous  to 
further  urethroscopy,  washed  thoroughly  in  liquid  soap,  we 
consider  our  technique  sufficient  to  obviate  any  accidental 
infection  of  the  urethra,  and  in  our  own  urethroscopic  examina- 
tions and  others  which  we  have  observed  we  have  never  seen 
the  slightest  evidence  of  infection  following  such  technique. 

In  the  use  of  the  urethroscopic  tubes,  whose  walls  are  neces- 
sarily thin,  care  must  be  exercised  not  to  dent  them,  as  any 
denting  causes  an  obstruction  in  the  lumen  of  the  tube,  prevent- 
ing the  easy  insertion  or  withdrawal  of  the  obturator.  This 
renders  the  tube  unfit  for  use. 

The  room  used  for  urethroscopic  examinations  should  be  so 
arranged  that  it  m.ay  be  made  fairly  dark  in  order  that  all  sources 
of  extraneous  light,  which  may  confuse  the  operator,  may  be 
obviated  as  nearly  as  possible.  A  dark  room  is  a  source  of  much 
comfort  and  satisfaction  to  the  urethroscopist. 


CHAPTER  III 
URETHROSCOPY  OF  THE  NORMAL  URETHRA 

The  indications  for  the  employment  of  the  urethroscope  in 
the  anterior  urethra  may  be  put  down  as  any  chronic  lesion  of 
that  part  of  the  urethra.  There  is  absolutely  no  means  other 
than  urethroscopy  by  which  we  can  obtain  a  comprehensive 
working  basis  in  such  conditions  and  it  should  be  considered  a 
sine  qua  non  in  the  diagnosis — a  rule  to  which  we  believe  there 
can  be  no  exceptions. 

When  urethroscopy  of  the  urethra  anterior  to  the  compressor 
has  been  decided  upon,  we  proceed  to  the  selection  of  the  tube. 
The  caliber  of  the  meatus  should  be  determined.  If  this  caliber 
be  smaller  than  22,  French,  meatotomy  must  be  done  as  urethros- 
copy with  a  tube  smaller  than  this  is  impractical. 

The  tube  selected  should  be  as  large  a  one  as  will  pass  com- 
fortably into  the  urethra.  We  do  not  agree  with  the  older 
teachings  that,  whatever  the  size  of  the  urethra,  the  tube  used 
in  the  first  examination  must  be  of  the  smallest  practical  caliber. 
This  arbitrary  rule  which  has  been  much  insisted  upon  in  the 
past  by  such  recognized  authorities  as  Oberlander,  Kollmann, 
and  Wossidlo  is  without  sound  reasoning  basis. 

The  position  the  patient  should  assume  during  an  examina- 
tion should  be  that  which  is  comfortable  for  the  patient  and 
which  will  permit  of  ease  in  manipulation  on  the  part  of  the 
operator.  Personally,  for  anterior  urethroscopy  we  prefer  the 
recumbent  posture. 

Occasionally,  preliminary  cocainization  of  the  urethra  may 
be  necessary  but  this  should  be  avoided  if  possible  on  account 
of  the  changes  produced  in  the  mucosa  by  its  use,  i.e.,  the  con- 
traction of  the  peripheral  vessels  and  the  mechanical  washing 

170 


URETHROSCOPY  OF  THE  NORMAL  URETHRA         171 

off  of  the  products  of  secretion  which  might  prove  of  diagnostic 
value.  When  cocainization  is  necessary,  we  have  found  a  i  per 
cent,  solution  of  sufficient  strength  to  produce  analgesia. 


Fig.  82  — Patient  in  position  for  urethcoscopy. 

The  glans  and  prepuce  should  be  thoroughly  cleansed  by 
washing  with  soap  spirits  and  water  and  the  penis  isolated  from 


172 


CYSTOSCOPY   AND   URETHROSCOPY 


its  surrounding  parts  by  means  of  a  sterile  towel  with  a  central 
hole.  These  towels  we  have  especially  made  for  this  purpose. 
The  urethroscopic  lamp  is  tested  to  see  that  it  is  working  satis- 
factorily and  the  rheostat  is  turned  to  the  point  where  the  neces- 


FiG.  83. — Introduction  of  urethroscope. 


sary  brilliancy  of  illumination  is  obtained.  The  obturator  is 
inserted  and  the  tube,  which  has  been  sterilized  according  to 
the  technique  explained  in  the  preceding  chapter,  is  well  lubri- 
cated.    As  a  lubricant  we  prefer  a  sterile  preparation  of  Irish 


URETHROSCOPY  OF  THE  NORMAL  URETHRA 


173 


moss.     There  are  several  excellent  lubricants  having  chondrus 
as  a  base  to  be  had  in  convenient  collapsible  tubes. 

The  penis  is  grasped  in  the  left  hand  and  the  prepuce  re- 
tracted.    The  lips  of  the  meatus  are  held  apart  by  retracting 


Fig.  84. — Urelhroscope  introduced   and   obturator  withdrawn.     Excess  secretion  is 
being  mopped  up  with  cotton-tipped  applicator. 

the  glans  on  each  side  with  the  thumb  and  forefinger  of  the  left 
hand  and  the  urethroscope  is  gently  inserted  until  the  resistance 
met  with  at  the  anterior  layer  of  the  triangular  ligament  is 
encountered.     Should  any  obstruction  to  the  insertion  of  the 


174 


CYSTOSCOPY   AND   URETHROSCOPY 


tube  be  met  with  prior  to  reaching  this  point,  the  urethroscope 
must  not  be  forced  past  it.  Even  a  shght  amount  of  force 
directed  against  such  an  obstruction  may  result  in  minute  tears 
or  fissures  in  the  mucosa.     We  have  seen  a  case  in  which  the 


Fig.  85. — Attaching  the  observation  window  preliminary  to  making  forced  air-inflation. 


obstruction  w^as  due  to  papillomata  and  in  which  the  operator 
used  undue  force,  causing  a  bleeding  which  rendered  all  attempts 
at  urethroscopy  unavailing  and  postponing  a  diagnosis  which 
should  have  been  readily  made.     The  obturator  is  withdrawn 


URETHROSCOPY  OF  THE  NORMAL  URETHRA 


175 


and  excess  secretion  is  gently  mopped  up  with  small  pledgets  of 
sterile  cotton  attached  to  applicators.  These  applicators  are 
made  of  wood  or  metal.  The  wooden  ones  are  in  every  way 
preferable.     Before   each   examination   a   number   are   freshly 


Fig.  86. — Window    attached    and    observation    being  carried    on    under  forced  air- 
inflation,  assistant  making  air-pressure  with  dilating  bulbs. 

prepared — from  twenty  to  thirty — and  each  applicator  so  tipped 
with  its  cotton  pledget  is  used  but  once.  This  facilitates  the 
examination  greatly  as  it  is  unnecessary  to  prepare  fresh  appli- 
cators during  the  seance.     Again,  should  the  applicator  be  not 


176 


CYSTOSCOPY   AND   URETHROSCOPY 


thoroughly  tipped  with  the  cotton,  danger  of  injury  to  the 
mucosa  from  the  point  of  the  wooden  ones  is  much  less  than  from 
those  made  from  metal.     Occasionally,  in  mopping  up  the  excess 


Fig.  87.— Introduction    of    urethroscope   into    posterior    urethra,    the    penis    being 
depressed  to  facihtate  passing  through  the  triangular  hgament. 


secretion,  the  moist  applicator  comes  in  contact  with  the  mignon 
lamp  and  from  this  moisture  on  the  lamp  there  sometimes  arises 
a  slight  vapor.  The  result  is  a  haziness  at  the  distal  end  of  the 
tube  which  may  confuse  the  operator.     A  dry  applicator  or  the 


URETHROSCOPY  OF  THE  NORMAL  URETHRA 


177 


inflation  of  the  urethra  with  air  readily  does  away  with  this 
slight  annoyance. 

The  urethroscope  is  slowly  withdrawn,  each  successive  field 
being  slowly  studied.     The  points  to  be  observed  as  being  of 


Fig.    88. — Urethroscope    introduced  for  intra-urethral  operative  procedure, 
duction  of  operating  instrument  attached  to  operating  window. 


Intro- 


diagnostic  value  are:  (i)  The  central-figure  (Griinf eld's  central- 
figur)  and  the  manner  in  which  the  urethra  falls  into  folds, 
which  varies  in  different  parts  of  the  canal.  (2)  The  vascularity 
of  the  mucosa.     (3)  The  appearance  of  the  mucosa  as  to  luster. 


178 


CYSTOSCOPY   AND    URETHROSCOPY 


(4)  The  appearance  of  the  orifices  of  the  lacunae  of  Morgagni 
and  the  glands  of  Littre. 

The  Elasticity. — Beginning  at  the  bulb  there  is  a  longitudinal 
folding  of  the  urethra  as  it  collapses  at  the  distal  end  of  the  ure- 


FiG.  89. — Intraurethral  operative  procedure  being  carried  on  under  forced  air-inflation 

and  direct  ocular  observation. 

throscope.  In  the  region  of  the  bulb,  these  longitudinal  folds 
are  quite  voluminous,  being  more  marked  on  the  inferior  wall. 
This  asymmetrical  folding  is  accounted  for  by  the  bulbar  cul-de- 
sac.     As  we  withdraw  the  urethroscope,  the  folds  become  less 


URETHROSCOPY  OF  THE  NORMAL  URETHRA         1 79 

voluminous  and  the  punctiform  central-figure  lengthens  out 
into  a  vertical  slit.  In  the  anterior  portion  of  the  scrotal  urethra, 
this  central-figure  becomes  punctiform  and  the  endoscopic 
figure  has  a  stellate  appearance,  reaching  its  greatest  symmetry 
in  the  mid-pendulous  portion.  At  the  isthmus  just  posterior 
to  the  navicular  fossa,  the  central-figure  changes  rather  abruptly 
to  a  vertical  slit  and  on  entering  the  navicular  fossa,  the  radiat- 
ing folds  disappear. 

The  readiness  with  which  the  urethra  falls  into  folds  depends 
upon  its  elasticity  and  the  size  of  the  urethroscopic  tube  used, 
it  being  readily  understood  that  the  larger  the  tube  the  less 
pronounced  the  folds.  The  elasticity  is  greatly  impaired  in  the 
infiltrations  which  are  an  accompaniment  of  chronic  gonorrheal 
urethritis,  and,  therefore,  this  folding  is  of  diagnostic  importance 
in  determining  the  extent  of  disease  and  the  progress  of  such 
lesions  under  treatment.  So  great  may  be  the  infiltration  that 
the  folds  may  be  almost  obliterated  and  we  have,  instead  of  the 
normal  infundibuliform  picture,  a  large  central  opening  with 
stiffened  walls  standing  out  from  the  end  of  the  urethroscopic 
tube.  With  air-inflation  it  is  possible  to  demonstrate  this  elas- 
ticity beautifully  and  with  extreme  accuracy.  By  releasing  the 
pressure  on  the  valved,  or  feeding  bulb  of  the  inflation  apparatus 
the  air  flows  back  into  the  retaining  bulb  allowing  the  urethra  to 
collapse  at  the  end  of  the  tube.  This  manipulation  may  be 
repeated  at  will  and  even  the  slightest  stiffness  in  the  urethra 
is  made  readily  perceptible. 

The  Vascularity. — Normally,  this  differs  in  degree  in  differ- 
ent individuals,  being  more  pronounced  in  the  well  nourished 
and  those  having  well-developed  organs,  and,  conversely,  being 
poorly  marked  in  anemic  conditions  and  where  the  genitals  are 
small  and  flaccid. 

The  region  of  the  glans  is  poor  in  blood  vessels  and  the 
urethra  in  this  neighborhocd  has  an  anemic  appearance.  Begin- 
ning at  the  navicular  fossa,  the  urethra  back  as  far  as  the  bulb 
is  traversed  by  minute  reddish  striae  of  vessels  running  longitu- 


l8o  CYSTOSCOPY   AND    URETHROSCOPY 

dinally  and  having  numerous  ramifications  on  a  background  of 
paler  mucosa,  which  has  a  slight  yellow  tinge.  Pathological 
infiltrations  markedly  modify  this  vascularity  and  to  the  trained 
observer  such  changes  are  readily  detected. 

Luster. — In  a  normal  condition  the  smooth  epithelial  sur- 
face combined  with  the  natural  vascularity  and  lubrication  of 
the  urethra  impart  to  the  urethroscopic  picture  a  characteristic 
luster.  Any  pathological  change  in  these  three  elements  mate- 
rially alters  this  normal  brilliancy  and  such  alterations  are  of 
diagnostic  importance. 

The  Appearance  of  the  Lacunae  of  Morgagni  and  the  Glands 
of  Littre. — Just  within  the  bulbar  cul-de-sac,  the  urethroscopist 
encounters  the  two  openings  of  the  glands  of  Cowper,  lying  about 
four  millimeters  apart.  On  account  of  the  large  number  and 
size  of  the  folds  in  this  region,  it  is  difficult  to  locate  these  open- 
ings with  the  ordinary  urethroscope  but  this  becomes  a  com- 
paratively easy  matter  under  air-inflation.  These  openings 
vary  greatly  in  different  urethrae  sometimes  appearing  as  easily 
observable  slit-like  orifices  and  again  as  hardly  appreciable 
reddish  punctae.  Occasionally  a  curious  congenital  malforma- 
tion is  encountered.  The  orifices  of  the  ducts  appear  as  V- 
shaped  openings,  the  point  of  the  V  being  placed  toward  the 
triangular  ligament.  Englisch  accounts  for  this  anomaly  on 
the  ground  of  lack  of  development  of  the  superior  wall  of  the 
duct.  This  lack  of  development,  which  we  have  encountered 
in  a  number  of  cases,  is  always  bilateral  and  is  not  readily  recog- 
nized except  under  air-inflation. 

As  the  urethroscope  is  withdrawn,  there  appear  on  the  supe- 
rior wall  a  number  of  punctiform  or  slit-like  openings — varying 
from  four  to  twelve — the  mouths  of  Morgagni' s  lacunae.  Ordi- 
narily it  is  possible  to  pass  the  tip  of  a  urethral  probe  into  these 
openings.  The  valve  of  Guerin,  located  in  about  three  centi- 
meters from  the  meatus,  is  the  largest  of  these  lacunae.  Their 
mouths  are  of  the  same  color  as  the  surrounding  mucosa  and  are 
not  raised  above  the  surface. 


Fig. 


90. 


Fig.  91.  Fig.  92. 

Fig.  90. — Normal  urethra  with  vascular  mucous  membrane. 
Fig.  91, — Normal  urethra  with  anemic  mucous  membrane. 
Fig.  92. — Soft  infiltration  (acute  urethritis;  beginning  of  the  chronic  form). 
de  Keersmaecker  and  Verhoogen.) 


(After 


URETHROSCOPY  OF  THE  NORMAL  URETHRA         l8l 

Normally,  the  openings  of  the  glands  of  Littre  are  not  visi- 
ble through  the  urethroscope  though,  in  a  diseased  condition, 
they  become  distinctly  perceptible  and  this  change  is,  as  a  rule, 
permanent. 

Posterior  Urethroscopy. — Urethroscopy  of  the  posterior 
urethra  is  essentially  different  from  that  of  the  anterior  and 
demands  a  greater  degree  of  skill  in  manipulation  for  reasons 
which  readily  suggest  themselves. 

The  normal  curvature  of  the  urethra  makes  access  to  that 
part  posterior  to  the  anterior  layer  of  the  ritangular  ligament 
difficult.  The  prostatic  mucosa  is  extremely  delicate  and  ex- 
hibits a  pronounced  tendency  to  bleeding  which  obscures  the 
field,  while  the  greater  degree  of  dilatability  of  this  region  requires 
considerable  manipulation  for  the  obliteration  of  the  numerous 
folds.  It  is  practically  impossible  to  avoid  traumatism,  though 
this  is  reduced  to  a  minimum  in  skilled  hands,  and  for  this  reason 
it  is  inadvisable  to  urethroscope  the  posterior  urethra  unless 
such  a  procedure  is  deemed  absolutely  essential. 

To  avoid  the  difficulties  detailed  above  a  number  of  instru- 
ments have  been  devised.  The  jointed  obturator  of  Oberlander, 
so  constructed  as  to  approximate  the  normal  urethral  curvature, 
has  not  been  received  with  much  favor,  w^hile  the  posterior  tube 
of  Swinburne  (see  Fig.  8i),  resembling  in  general  a  short  curved 
sound,  has  found  much  wider  acceptance,  though  it  is  open  to 
two  valid  objections — the  fact  that  with  this  instrument  it  is 
possible  to  observe  only  a  limited  area  confined  to  the  floor  of 
the  urethra,  and  that  manipulation  for  the  purpose  of  minute 
observation  of  the  urethroscopic  field  is  too  restricted.  For  the 
purpose  of  inspection  and  diagnosis  the  instruments  of  Buerger, 
or  of  McCarthy,  mentioned  in  the  preceding  chapter,  give  excel- 
lent service. 

Our  personal  preference  is  for  the  straight  posterior  tubes 
with  the  air-inflation  attachment.  It  requires  no  great  skill 
for  their  introduction  with  the  minimum  of  trauma  and  the  air- 
inflation  feature  obviates  the  necessity  for  painful  manipulation. 


l82  CYSTOSCOPY   AND   URETHROSCOPY 

It  is  in  this  region  that  the  remarkable  advantages  of  air-inflation 
present  themselves  so  prominently. 

Previous  to  the  introduction  of  the  urethroscope,  the  pos- 
terior urethra  is  cocainized  either  by  means  of  the  tablet 
depositor  described  in  the  technique  of  cystoscopy  (page  25) 
or  by  the  instillation  of  thirty  minims  of  a  5  per  cent,  solution 
of  cocaine,  the  bladder  having  been  emptied  prior  to  cocainiza- 
tion  and  the  patient  urinating  again  immediately  before  the 
urethroscopy.  The  cocaine  is  allowed  to  remain  for  about  five 
minutes,  the  length  of  time  usually  required  for  thoroughly 
obtunding  the  sensibility  of  the  urethra. 

The  position  of  the  patient  for  posterior  urethroscopy  is  a 
point  of  importance  and  should  conform  to  the  rule  laid  down 
on  page  170  for  anterior  urethroscopy,  i.e.,  it  must  be  that  which 
is  comfortable  for  the  patient  and  which  will  permit  of  ease  in 
manipulation  on  the  part  of  the  operator.  The  position  which 
best  jftlls  these  requirements  is  a  half-sitting  one,  and  is  fully 
explained  by  Fig.  82. 

The  urethroscopic  tube  is  inserted  as  in  anterior  urethroscopy 
until  the  resistance  met  with  at  the  anterior  layer  of  the  triangu- 
lar ligament  is  encountered.  The  proximal  end  of  the  instru- 
ment is  then  depressed  with  the  right  hand  while  the  fingers  of 
the  left,  by  pressure  over  the  perineal  urethra,  elevate  the  point 
of  the  tube  from  the  bulbar  cul-de-sac  into  the  membranous 
urethra.  The  instrument  is  then  slowly  pushed  in  until  it 
enters  the  bladder. 

The  obturator  is  removed  and  the  excess  secretion  mopped  up. 
The  urethroscope  is  withdrawn  until  it  enters  the  prostatic 
urethra  which  is  readily  recognized.  If  bleeding  obscures  the 
field,  as  it  may  do  even  with  the  most  careful  manipulation,  it 
is  advisable  to  swab  the  surface  with  a  solution  of  suprarenal 
extract.  The  resultant  blanching  of  the  mucosa  must  be  taken 
into  consideration. 

The  points  of  particular  importance  to  be  observed  in  this 
region  are  the  general  aspect  of  the  mucosa,  the  verumontanum, 


URETHROSCOPY  OF  THE  NORMAL  URETHRA         1 83 

the  prostatic  utricle,  and  the  orifices  of  the  prostatic  and  ejacu- 
latory  ducts.  It  will  be  noted  that  the  mucosa  has  a  much  red- 
der appearance  than  that  of  the  anterior  urethra  and  has  not 
the  peculiar  luster  or  vascular  striations. 

The  verumontanum  varies  greatly  in  different  individuals 
and  is  also  much  modified  by  sexual  excesses  and  disease.  In 
anemic  persons  and  in  those  whose  vita  sexualis  is  slight,  the 
verumontanum  will  be  correspondingly  poorly  developed  and, 
conversely,  in  sexually  vigorous  individuals,  the  verumontanum 
will  be  prominent. 

Norm.ally  it  has  an  extent  of  from  one  to  two  centimeters 
in  the  direction  of  the  canal  and,  in  its  most  prominent  part, 
is  of  about  the  size  of  a  small  pea,  though  under  the  influence  of 
disease  or  excesses  it  may  assume  much  larger  proportions  and 
become  extremely  turgescent. 

In  about  the  center  of  the  anterior,  or  most  prominent 
part  of  the  verumontanum  will  be  found  the  sinus  pocularis, 
which  has  as  great  variations  as  the  caput  gallinaginis.  It  may 
be  noted  as  a  small  depression  or  a  relatively  deep  excava- 
tion. Its  depth  has  apparently  no  relation  to  the  size  of  the 
veru  montanum. 

Ordinarily,  in  a  condition  of  health,  it  is  impossible  to  recog- 
nize the  openings  of  the  prostatic  ducts  through  the  urethroscope 
though  in  disease  they  often  become  distinctly  visible,  taking 
on  much  the  same  appearance  as  the  orifices  of  the  glands  of 
Littre  under  similar  conditions.  The  orifices  of  the  prostatic 
ducts  are  scattered  along  the  sides  of  the  caput  gallinaginis  and 
are  from  twelve  to  twenty  in  number. 

The  orifices  of  the  ejaculatory  ducts  are  situated  forward  of 
the  verumontanum  on  the  edges  of  the  prostatic  utricle,  some- 
times being  found  just  within  its  margins.  They  are  easily 
seen  and  are  larger  than  is  usually  taught,  readily  admitting 
the  tip  of  the  urethral  probe. 

In  ordinary  urethroscopy,  the  central-figure  in  the  prostatic 
urethra  appears  as  an  inverted  U,  the  upward  projection  being 


184  CYSTOSCOPY   AND    URETHROSCOPY 

formed  by  the  verumontanum  while  the  superior  wall  falls 
around  it  closely  in  folds  more  delicate  and  numerous  than 
those  of  the  penile  urethra.  In  this  collapsed  condition,  a  great 
deal  of  dexterous  manipulation  is  necessary  to  examine  this 
region  in  detail  and  the  recognition  of  lesions  and  their  extent  is 
rendered  extremely  difficult.  Under  air-  or  water-inflation  the 
numerous  folds  are  obliterated,  the  essential  manipulation  is 
reduced  to  a  minimum  and  the  different  landmarks  and  lesions 
are  readily  identified.  There  can  be  no  question  of  its  decided 
advantages  in  this  portion  of  the  canal.  As  the  instrument  is 
withdrawn,  the  projection  formed  by  the  verumontanum  grows 
abruptly  less  and  disappears  entirely  before  the  extreme  forward 
portion  of  the  prostatic  urethra  is  reached. 

Leaving  the  prostatic  urethra,  the  instrument  passes  through 
the  posterior  reflection  of  the  triangular  ligament  and  enters 
the  membranous  urethra.  The  urethroscopic  characteristics  in 
this  portion  of  the  canal  are  the  great  vascularity  and  the 
punctiform  central-figure  with  numerous  delicate  radiating 
folds.  Occasionally,  a  prominence  is  noticed  upon  the  inferior 
wall  extending  into  the  bulbar  portion  which  suggests  to  a 
slight  degree  the  verumontanum.  This  similarity  has  led  some 
observers  into  incorrectly  interpreting  it  as  a  prolongation  of  the 
verumontanum.  According  to  Oberlander  it  corresponds  to  the 
location  of  the  ducts  of  Cowper's  glands. 

The  Female  Urethra.— On  account  of  its  shortness  and  its 
almost  entire  lack  of  glandular  structure,  the  female  urethra 
presents  but  few  points  of  interest  to  the  urethroscopist. 

For  the  purposes  of  urethroscopy  the  short  tubes  used  for 
anterior  urethroscopy  in  the  male  are  sufficient.  The  large 
caliber  and  extreme  degree  of  dilatability  of  the  canal  in  the 
female  permit  of  the  use  of  tubes  of  large  caliber.  The  external 
meatus  is  the  narrowest  part  of  the  urethra  and  preliminary 
meatotomy  is  sometimes  required. 

The  gynecologic  position  with  pelvis  elevated  is  by  far  the 
best  posture  for  both  operator  and  patient. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA         1 85 

The  vulva  and  vaginal  vestibule  are  thoroughly  cleansed  and 
the  labia  are  held  apart  by  the  thumb  and  forefinger  of  the  left 
hand.  The  bladder  is  catheterized.  The  urethroscope,  well 
lubricated,  is  inserted  through  the  urethra  into  the  bladder  and 
the  excess  moisture  mopped  up  with  the  cotton- tipped  applica- 
tors. It  is  now  withdrawn  until  it  enters  the  grasp  of  the  com- 
pressor urethrae.  This  point  is  readily  recognized  by  the  pecul- 
iar symmetrical  folding  of  the  canal  as  opposed  to  the  picture 
presented  while  the  urethroscope  is  still  within  the  bladder. 
The  urethroscopic  appearance  is  almost  identical  with  that  of 
the  membranous  urethra  in  the  male.  The  folds  are  numerous 
and  delicate.  The  central-figure  is  punctate.  Farther  for- 
ward the  central-figure  becomes  a  vertical  slit  and  the  folds  less 
numerous  and  more  voluminous.  Near  the  meatus  the  same 
vascular  striations  noticed  in  the  anterior  urethra  in  the  male  are 
observable  but  near  the  bladder  the  vascular  striations  become 
so  merged  as  to  be  noticeable  only  under  extreme  dilatation. 

Just  within  the  meatus  on  the  floor  are  found  the  two  open- 
ings of  Skene's  ducts.  As  they  are  observable  without  resorting 
to  urethroscopy,  they  hold  but  little  interest  for  the  urethro- 
scopist. 

Occasionally,  as  the  urethroscope  is  withdrawn  from  the 
bladder  a  projection  is  noticed  springing  from  the  floor  of  the 
urethra.  This  projection  is  due  to  the  extension  of  the  angle  of 
the  vesical  trigone  and  is  analogous  to  the  verumontanum  in  the 
male. 


CHAPTER  IV 
URETHROSCOPY  OF  THE  DISEASED  URETHRA 

THe  correct  interpretation  of  the  pathological  changes  found 
in  the  urethra  via  urethroscopy  necessarily  presupposes  a 
thorough  knowledge  of  the  normal  urethroscopic  pictures. 
This  knowledge  can  come  only  with  practical  observation 
through  the  urethroscope  and  requires  a  wide  clinical  experience. 
Opportunity  for  urethro scoping  the  normal  urethra  very  seldom 
presents  itself  and  in  the  preceding  chapter  we  have  endeavored 
to  supply  this  deficiency  in  text. 

In  this  chapter,  the  pathological  urethra  will  be  considered  in 
detail  and  this  consideration  embodies,  primarily,  the  elemental 
changes  produced  by  chronic  urethritis.  These  changes  are  so 
multiform  in  character  that  we  find  it  expedient  to  classify 
them  under  the  same  general  headings  that  we  have  applied  to 
the  normal  urethroscopic  picture,  viz:  (i)  The  changes  in  the 
elasticity.  (2)  The  modifications  in  the  vascularity.  (3)  The 
changes  in  the  luster.  (4)  The  appearance  of  the  pathological 
lacunae  of  Morgagni  and  glands  of  Littre. 

The  Changes  in  the  Elasticity. — Neelsen  and  Finger  have 
conclusively  shown  that  the  essential  lesion  of  chronic  urethritis 
/  is  a  connective- tissue  change.  This  connective-tissue  prolifera- 
tion begins  in  the  acute  form  of  the  disease  as  a  round-cell 
infiltration  and  is  seen  in  a  progressive  degree  in  the  chronic 
form.  Based  on  the  researches  of  Neelsen  and  Finger,  Ober- 
lander  has  classified  these  changes  as:  (i)  Soft  infiltration, 
(2)  hard  infiltration.  Oberlander's  soft  infiltration  has  prac- 
tically the  same  characteristics  as  the  circumscribed  hyperemia 
first  described  by  Furstenheim.  To  the  latter  form  he  ascribes 
three  grades  or  degrees.  Of  this  subdivision  we  shall  speak  later, 
in  considering  the  glandular  modifications. 


URETHROSCOPY   OF    THE   DISEASED    URETHRA  187 

The  characteristic  folding  of  the  urethra  with  the  resultant 
central-figure  is  dependent  upon  the  elasticity.  As  a  result  of 
the  infiltration  which  takes  place  in  chronic  urethritis,  there  is  a 
consequent  stiffening  of  the  urethral  wall.  This  stiffening 
varies  in  degree  from  a  slight  loss  of  elasticity  to  the  absolute 
rigidity  of  the  most  pronounced  form,  Oberlander's  third  degree 
of  hard  infiltration,  or  stricture.  All  degrees  of  loss  of  elasticity 
may  be  found  in  the  same  urethra,  the  lesser  degrees  shading  off 
from  the  extreme  form  as  a  center. 

Soft  infiltration  in  reality  belongs  to  acute  urethritis  and 
therefore  hardly  belongs  in  the  realm  of  urethroscopy.  In  the 
transitional  form  from  soft  infiltration  to  the  first  degree  of  hard 
infiltration  it  is,  however,  often  observable.  In  this  transitional 
form  the  central  figure  is  only  slightly  modified.  The  funnel 
formed  by  the  collapsed  urethra  is  larger  than  under  normal 
conditions  and  as  the  urethroscope  is  withdrawn,  the  tendency 
to  the  longitudinal  folding  of  the  mucosa  is  not  as  decided  as  in 
the  normal  urethra.  The  elasticity  is  apparently  retarded,  not 
destroyed,  and  to  the  trained  observer,  this  sluggishness  in  the 
folding  is  characteristic. 

The  tendency,  if  we  may  call  it  such,  toward  lack  of  elas- 
ticity observed  in  soft  infiltration  becomes  decidedly  more 
marked  when  the  stage  of  hard  infiltration  is  entered  upon. 
The  funnel  at  the  end  of  the  urethroscope  becomes  much 
elongated  and  the  urethra,  which  normally  collapsed  in  fairly 
regular  folds,  is  seen  to  collapse  irregularly,  the  area  of  infiltra- 
tion being  marked  by  a  decided  stiffness  and  an  almost  entire 
lack  of  folds.  As  this  infiltration  progresses  the  folds  decrease 
proportionately  until,  in  the  most  extreme  degree,  these  folds 
disappear  entirely  and  the  central  figure  becomes  an  irregular 
opening,  the  sides  of  which  have  a  crinkled  appearance  and  are 
not  in  contact. 

We  may  have,  then,  an  area  of  extreme  hard  infiltration,  at 
both  the  proximal  and  distal  periphery  of  which  may  be  found 
this  infiltration  in  varying  degrees.     Occasionally,  this  transi- 


156  CYSTOSCOPY   AND    URETHROSCOPY 

tional  form  is  not  present  at  the  proximal  end  but  is  practically 
always  observable  on  the  distal  side  of  hard  infiltration  of  the 
pronounced  type. 

Modifications  in  the  Vascularity. — In  the  vascularization  of 
the  urethra,  infiltration  produces  decided  changes.  In  soft 
infiltration  and  in  the  transitional  form,  there  is  a  passive  hy- 
peremia. The  vascular  striations  are  not  as  delicately  marked 
and  the  normally  pinkish-yellow  mucosa  which  forms  their 
background  is  turgescent  and  of  a  purplish-red.  As  the  infiltra- 
tion advances  this  turgescence  gradually  fades  from  the  center 
toward  the  periphery.  The  strangulation  of  the  vessels  by  the 
forming  fibrous  tissue  produces  an  obliteration  of  the  longitud- 
inal striations  and  their  ramifications  with  a  resultant  anemia. 
The  mucosa  becomes  pale  yellow  and  finally  takes  on  an  eschar- 
otic  appearance  in  the  advanced  grades  of  infiltration. 

Occasionally,  in  an  anemic  urethra,  the  careless  observer 
may  be  misled  by  the  apparently  abnormal  lack  of  blood  supply. 
Closer  observation  will  disclose  the  vascular  striae  and  even 
should  these  be  not  observed,  the  normal  elasticity  will  dispel 
the  possibility  of  the  anemia  being  due  to  infiltration. 

The  Changes  in  the  Luster. — In  its  normal  condition,  the 
epithelial  layer  of  the  urethra  is  smooth  and  in  combination 
with  the  natural  moisture  and  vascularity  gives  a  characteristic 
brilliancy  to  the  urethroscopic  picture.  In  the  superficial  forms 
of  soft  infiltration  this  luster  is  enhanced.  But  with  the  pro- 
gression of  the  infiltration  and  the  consequent  nutritive  changes 
there  ensues  a  desquamation.  This  desquamative  process  pro- 
vokes irregularities  in  the  epithelium  and  it  loses  its  smooth 
transparency.  It  is  roughened  and,  on  close  observation,  has  a 
tufted  appearance  due  to  epithelial  proliferation.  These  tufts 
vary  in  dimension,  occasionally  extending  over  an  area  of  several 
millimeters. 

In  the  advanced  grades  of  infiltration,  the  lack-luster  appear- 
ance of  the  epithelium  is  characteristic.  It  is  dull  and  grayish- 
yellow.     Through  this  layer  of  infiltration,  the  redder  mucosa 


Fig.  93. 


Fig.  94.  Fig.  95. 

Fig.  93. — Glandular  urethritis.     Hard  infiltration  of  the  first  degree. 
Fig.  94. — Same  form  as  Fig.  i,  under  treatment. 
Fig.  95. — Same  form  as  Figs,  i  and  2,  nearly  cured. 
(After  de  Keersmaecker  and  Verhoogen.) 


URETHROSCOPY   OF    THE   DISEASED   URETHRA  1 89 

beneath  may  sometimes  be  observed  as  though  obscured  by  a 
veil.  * 

The  Appearance  of  the  Pathologic  Lacunae  of  Morgagni  and 
the  Glands  of  Littre. — In  Oberlander's  most  excellent  classifica- 
tion of  chronic  urethritides,  into  soft  and  hard  infiltration,  he 
recognizes  three  degrees  of  the  latter,  the  first  and  second  degrees 
being  marked  by  glandular  changes.  These  glandular  modifica- 
tions are  of  much  interest  to  the  urethroscopist  and  upon  their 
recognition  depends  much  of  the  intelligent  treatment  of  chronic 
urethritis. 

Broadly  considered,  Oberlander  recognizes  a  glandular  form  in  ' 
which  the  excretory  duct  is  patent  and  a  dry  form  which  is  charac- 
terized by  an  obstruction  of  the  excretory  duct.     As  a  result  of  this  , 
obstruction,  the  gland  may  become  C3^stic  or  entirely  obliterated.  ' 

In  Oberlander's  first  degree  of  hard  infiltration,  the  first 
noticeable  changes  in  the  glands  are  found.  They  are  usually 
found  in  small  scattering  groups.  In  the  glandular  form  they  ^ 
appear  slightly  swollen  and  red.  The  infiltration  surrounding 
them  is  superficial  and  has  the  appearance  of  the  transitional 
form  from  soft  into  hard  infiltration.  This  transitional  infiltra- 
tion, if  we  may  so  designate  it,  is  hardly  ever  seen  surrounding 
the  excretory  ducts. 

In  the  dry  form  of  this  degree  the  excretory  ducts  are  - 
obstructed  and  the  glands  become  rapidly  cystic.  If  these 
glands  are  superficially  placed  they  appear  as  small  translucent 
vesicles  of  about  the  dimensions  of  a  canary  seed.  The  excre- 
tory ducts  are  not  visible,  but  their  location  may  be  marked  by 
small  radiating  cicatrices. 

In  the  glandular  form  of  the  second  degree  of  hard  infiltration 
the  process  indicated  in  the  first  glandular  changes  is  found  in  an 
accentuated  form.  The  grouping  of  the  glands  is  more  marked 
and  takes  on  a  compactness,  in  contradistinction  to  the  scattering 
tendency  noticeable  in  the  earlier  stages.  This  grouping  is 
met  with  especially  at  the  peno-scrotal  juncture. 

*  Chronic  Urethritis  of  Gonococcic  Origin,  J.  DeKeersmaecker  and  J.  Verhoogen. 


igo  CYSTOSCOPY   AND    URETHROSCOPY 

The  location  of  the  excretory  duct  is  well  marked  and  sur- 
rounded by  a  pronounced  inflammatory  zone.  These  glandular 
changes  are  made  readily  perceptible  upon  the  inferior  wall,  on 
account  of  the  more  superficial  situation  of  the  glands.  For 
this  same  reason,  the  glandular  changes  on  the  inferior  wall 
disappear  more  rapidly  under  treatment. 

In  the  dry  form  of  the  second  degree  of  hard  infiltration,  the 
obstruction  of  the  excretory  duct  is  more  chronic  in  character 
and  decidedly  more  cicatricial.  For  this  reason  the  glands 
themselves  show  a  decided  tendency  toward  obliteration  by 
rupture  into  the  surrounding  tissue  or  by  fibrous  encapsulation. 
The  glands  show  as  small  nodular  masses  and  at  no  time  are  the 
small  canary-seed  vesicles  found.  The  tendency  toward  group- 
ing is  entirely  lost,  and  the  noticeable  changes  are  isolated. 

The  Lacunae  of  Morgagni. — The  Lacunae  of  Morgagni  par- 
ticipate in  the  glandular  changes  of  chronic  urethritis  in  a  manner 
analogous  to  those  changes  which  take  place  in  the  glands  of 
Littre.  The  pathologic  process  is  much  more  easily  observed  in 
the  lacunae  on  account  of  their  larger  size. 

In  the  earlier  stages  of  chronic  urethritis,  the  opening  of  the 
lacuna  which,  in  a  normal  state,  is  of  the  same  color  as  the  sur- 
rounding mucosa  and  is  not  raised  above  the  surface,  shows  a 
pronounced  change.  The  mouth  is  turgescent  and  red  and  the 
epithelial  luster  is  greatly  modified.  At  the  same  time  a  muco- 
purulent secretion  may  be  seen  issuing  from  the  mouth  of  the 
lacuna. 

The  different  degrees  of  infiltration  may  attack  the  lacunae 
with  varied  results.  The  orifices  may  become  widely  dilated  by 
the  contracting  infiltration.  The  urethroscopic  picture  is  typ- 
ical. The  edges  of  the  orifice  are  everted  and  reddened  and  sur- 
rounding this  everted  orifice  is  a  zone  of  paler  infiltration. 

Instead  of  an  enlarged  pouting  orifice,  the  lacuna  may  present 
an  obstructed  condition  with  a  resultant  cyst  of  the  lacuna. 
The  cyst  has  not  the  translucent  vesicular  appearance  of  similar 
cysts  of  Littre' s  glands,  but  appears  as  a  red  nodule,  the  contents 


Fig.  q6. 


Fig.  97. 


Fig.  98. 


Fig.  99.  Fig.  100. 

Fig.  96. — Mixed  urethritis,  hard  infiltration  of  the  second  degree. 

Fig.  97. — Dry  urethritis,  infdlration  of  the  second  degree. 

Fig.  98. — Dry  urethritis,  hard  infiltration  of  first  degree,  vesicles  are  present. 

Fig.  99. — Dry  urethritis  showing  large  submucous  nodosities. 

Fig.  100. — Dry  urethritis,  infiltration  of  second  degree. 

(After  de  Keersmaecker  and  Vcrhoogen.) 


Fig.  ioi. 


Fig.  I02.  Fig.  103. 

Fig.   ioi. — Membranous  urethra  in  normal  state. 

Fig.  102. — Normal  prostatic  urethra. 

Fig.  103. — Urethritis  of  the  prostatic  portion. 

(After  de  Keersmaecker  and  Verhoogen.) 


URETHROSCCPY    OF    THE    DISEASED    URETHRA  19I 

of  which  may  rupture  into  the  surrounding  tissues.  In  this 
cystic  type  of  lacunar  involvement,  it  is  extremely  difficult  to 
make  out  the  orifices  of  the  lacunae.  The  lacuna  may  rupture 
into  the  canal  and  become  transformed  into  a  longitudinal  slit 
at  the  bottom  of  which  may  be  observed  the  orifices  of  infected 
glands  of  Littre.  Occasionally,  granulation  tissue  is  observed — 
the  urethritis  granulosa  of  Oberlander.  These  granulations 
resemble  to  a  great  degree  the  peculiar  granular  points  of 
trachoma. 

The  Posterior  Urethra.- — As  indicated  in  the  chapter  on  nor- 
mal urethroscopy,  the  posterior  urethra  should  not  be  thus 
invaded  until  the  lesions  therein  are  decidedly  chronic.  Soft 
infiltration  and  the  transitional  form  are  not  to  be  observed  as 
pure  clinical  entities,  though  they  may  be  found  in  a  condition  of 
retrograde  metamorphosis  or  at  the  periphery  of  the  areas  of 
hard  infiltration. 

In  the  prostatic  urethra,  we  find  areas,  or  plaques,  of  sclerotic 
appearing  mucosa.  These  areas  of  infiltration  never  attain  the 
degree  of  stricture  formation,  properly  speaking,  that  is  found  in 
the  anterior  urethra.  The  characteristic  folding  of  the  urethra 
is  not  markedly  modified. 

On  account  of  the  small  number  of  Littre' s  glands  found  in 
this  region,  their  pathology  is  unimportant.  The  most  notice- 
able changes  are  found  in  the  verumontanum,  the  prostatic 
utricle,  the  ejaculatory  ducts  and  the  prostatic  ducts. 

The  verumontanum  in  a  state  of  soft  infiltration  is  turgescent 
and  has  a  peculiar  dull,  cyanotic  aspect.  It  bleeds  more  readily 
than  in  health  and  its  surface  may  appear  creased  or  wrinkled. 
The  utricle  is  gaping  and  of  a  deeper  red  color.  The  mucosa  may 
have  a  "plushed"  appearance. 

In  the  hard  infiltration  the  verumontanum  seems  to  flatten 
out  and  has  a  sclerotic  appearance.  This  pachydermic  appear- 
ance may  be  limited  to  small  areas  in  the  midst  of  a  turges- 
cent periphery. 

In  this  form  of  chronic  posterior  urethritis,  the  prostatic 


192  CYSTOSCOPY   AND    URETHROSCOPY 

utricle  may  take  on  changes  analogous  to  those  observable  in 
Morgagni's  lacunae.  Its  edges  may  become  everted  and  red- 
dened. If  it  is  of  small  dimensions  normally,  the  infiltration 
may  close  the  orifice  sufficiently  to  form  a  distinct  cyst.  In  the 
earlier  forms  of  infiltration  the  orifices  of  the  ejaculatory  ducts, 
normally  slit-like  and  of  the  same  color  as  the  surrounding 
mucosa,  assume  a  more  rounded  shape,  are  slightly  raised  above 
the  contiguous  surrounding  surface  and  have  a  surrounding 
reddish  zone.  As  the  infiltration  progresses,  two  changes  may 
take  place.  The  orifices  may  become  dilated  with  slightly 
everted  edges,  giving  rise  to  a  pouting  appearance  or  the  infiltra- 
tion may  cause  a  stenosis  at  the  orifice.  The  former  is  most 
usual,  but  it  must  not  be  forgotten  that  even  with  a  dilated, 
pouting  orifice,  a  deeper  infiltration  may  cause  a  stenosis  back  of 
the  orifice. 

The  orifices  of  the  prostatic  ducts,  barely  observable  in  health, 
take  on  changes  analogous  to  those  observed  in  the  glands  of 
Littre  in  the  anterior  urethra  and  the  analogy  is  so  close  that  the 
changes  taking  place  in  them  under  the  influence  of  chronic 
urethritis  require  no  especial  description. 

The  Membranous  Urethra.- — In  this  part  of  the  canal  we  find 
changes  similar  to  those  taking  place  in  the  anterior  urethra. 
Littre' s  glands  are  few  in  number  in  the  membranous  portion 
and  are  even  less  developed  than  they  are  in  the  prostatic  por- 
tion. For  this  reason,  glandular  changes  are  seldom  capable  of 
demonstration  here.  We  find  the  different  degrees  of  infiltra- 
tion and  this  infiltration  practically  always  extends  from  the 
bulbous  region.  With  the  exception  of  the  glandular  form,  which 
is  never  encountered  in  the  membranous  region,  the  modifica- 
tions in  the  endoscopic  picture  are  of  the  same  character  as  those 
which  are  found  in  the  anterior  urethra.  The  characteristic 
changes  in  the  luster  and  the  folds  are  easily  identified  and 
require  no  especial  description. 

Stricture. — In  Oberlander's  classification  of  the  different 
degrees  of  infiltration  already  referred  to  in  the  study  of  chronic 


URETHROSCOPY    OF    THE   DISEASED    URETHRA 


193 


I  A  i 


Fig.  104. 


Fig.  105. 


Fig.  106. 


Fig.  107. 


Fig.  108. 


Fig.  109. 


Fig.  1 10.  Fig.  hi.  Fig.  112. 

Fig.  104. — Floor  of  Ihe  proximal  portion  of  the  supramontani  region  when  this  forms 

a  valley  surmounted  by  prominent  side  walls. 

Fig.   105. — Normal  colliculus  with  prominent  posterior  frenula. 

Fig.   106. — Normal  colliculus  viewed  from  in  front  (distally).     Presenting  summit  and 

acclive. 

Fig.   107. — Atypical  colliculus  with  peculiar  utricle. 

Fig.  108. — Small  cysts  in  roof  of  the  pars  supramontana 

Fig.  109. — Fossula  prostatica  and  declive. 

Fig.  1 10. — Inflammatory  excrescences  on  the  colliculus. 

Fig.   III. — Small  papilloma  lying  against  colliculus  and  arising  by  a  slender  pedicle 

from  the  foot  of  that  body. 

Fig.   1X2. — Enlarged  prostatic  duct  in  depressed  scar  tissue  in  the  right  sulcus  lateralis; 

displaced  and  distorted  colliculus. 

(After  Leo  Buerger.) 

13 


194  CYSTOSCOPY   AND   URETHROSCOPY 

urethritis,  he  classifies  stricture  in  the  third  degree  of  hard  infil- 
tration, i.e.,  that  infiltration  that  has  progressed  to  such  a  degree 
that  it  precludes  the  passage  of  an  instrument  as  large  as  num- 
ber 23,  Charriere  scale.  This  classification  is  arbitrary  and  must 
be  abandoned  in  the  endoscopic  study  of  stricture,  as  it  will  be 
readily  understood  that  infiltration  to  the  degree  of  stricture 
formation  is  encountered  at  a  larger  caliber  than  number  23, 
French. 

Finger  has  shown  that  the  connective-tissue  proliferation 
which  eventually  ends  in  gonorrheal  stricture  practically  always 
has  its  beginning  in  the  glandular  recesses.  This  process  begins 
in  the  mucosa,  later  extends  to  the  submucosa  and  over  into  the 
erectile  tissue  of  the  corpora  cavernosa  unless  checked.  As  a 
result  of  this  connective-tissue  proliferation  there  is  produced  a 
strangulation  of  the  vessels  with  a  resultant  anemia. 

To  the  urethroscopist,  stricture  appears  as  an  encroachment 
on  the  lumen  of  the  urethra,  having  the  characteristic  appearance 
of  extreme  hard  infiltration.  Its  appearance  is  sclerotic — a 
cadaverous  yellowish  white — and  the  epithelial  luster  has  dis- 
appeared. There  is  a  complete  absence  of  the  longitudinal  folds 
in  the  infiltrated  area.  This  infiltration  may  present  at  any 
part  of  the  urethral  lumen.  The  first  noticeable  encroachment  on 
the  lumen  anterior  to  the  bulbous  portion  is  usually  observed  on 
the  superior  half  of  the  urethral  wall,  preferably  to  one  side  of 
the  center.  An  encroachment  beginning  on  the  inferior  wall  is 
extremely  unusual  in  gonorrheal  stricture,  except  in  the  bulbous 
portion  of  the  canal,  where  the  beginning  sclerosis  is  usually  on 
the  floor. 

From  its  point  of  inception  the  infiltration  extends,  showing 
the  characteristic  transitional  forms  toward  the  periphery.  This 
extension  is  more  marked  in  an  antero-posterior  direction,  though 
frequently  the  lateral  growth  is  proportionately  rapid. 

While  the  diagnosis  of  an  obstruction  in  the  urethral  lumen  is 
readily  made  by  means  of  flexible  bougies  a  boule,  the  urethro- 
scope holds  an  invaluable  place  in  the  diagnosis.     By  its  use  we 


URETHROSCOPY   OF    THE   DISEASED   URETHRA  1 95 

are  able  to  determine  the  clinical  variety  of  the  stricture,  the 
point  of  extreme  infiltration,  the  presence  or  absence  of  compli- 
cating papillomata,  the  presence  or  absence  of  false  passages  and 
the  relative  location  of  the  stricture  to  the  urethral  lumen.  The 
latter  point  is  of  extreme  importance  in  the  accurate  treatment 
of  stricture. 

In  stricture  of  filiform  caliber  where  there  is  great  distortion 
of  the  tissues,  the  location  of  the  lumen  of  the  stricture  is  readily 
determined  by  air-inflation  urethroscopy.  In  such  cases  its 
value  is  beyond  question. 

The  different  clinical  varieties  of  stricture  are  easity  recog- 
nized by  the  urethroscopist.  Their  nomenclature  suggests 
their  urethroscopic  appearance  and  a  detailed  description  of 
each  is  superfluous. 

False  passages  are  by  no  means  an  infrequent  accompaniment 
of  small  cahbered  stricture  and  their  recognition  is  not  always 
easy,  i.e.,  their  dift'erentiation  from  the  actual  lumen  of  the 
stricture.  In  false  passage  of  comparatively  recent  origin,  the 
diagnosis  is  easily  made.  The  use  of  air-inflation  is  of  great 
value  in  these  cases.  By  its  means  a  wider  field  anterior  to 
the  obstruction  is  obtained  and  a  comparison  of  the  false  and 
true  openings  is  readily  made.  Where  false  passages  are  present 
we  find  in  the  sclerosed  tissue  forming  the  stricture,  two  or  more 
openings,  one  of  which  is  the  true  strictural  lumen.  The  orifice 
of  the  latter  is  characterized  by  the  extreme  degree  of  infiltra- 
tion. The  edges  of  the  opening  are  rounded,  not  ragged  or 
clear-cut.  The  gentle  introduction  of  a  urethral  probe  into  the 
opening  does  not  provoke  bleeding. 

The  opening  of  the  false  passage  presents  a  different  appear- 
ance. It  is  situated  away  from  the  area  of  greatest  infiltration. 
Its  edges  are  ragged.  If  recent  its  orifice  is  usually  closed  by  a 
clot  of  blood.  The  introduction  of  a  urethral  probe  even  with 
great  gentleness  produces  bleeding.  Even  in  false  passage  of 
long  duration,  its  appearance  is  characterized  by  more  recent 
infiltration  than  the  true  lumen  and  careful  comparison  of  the 


196  CYSTOSCOPY   AND   URETHROSCOPY 

two  openings  can  hardly  result  in  a  mistaken  differentiation. 
Fenwick,  who  is  an  ardent  supporter  of  air-inflation  urethroscopy, 
relates  the  following  case  which  is  of  interest  as  it  presents  an 
"accident"  occurring  under  the  use  of  air-inflation,  the  possi- 
bility of  which  must  not  be  ignored  in  similar  cases. 

"I  examined  with  inflation  a  patient  who  had  had  profuse 
bleeding  from  attempts  at  catheterism  some  few  hours  before 
applying  to  me  for  relief.  I  was  able  to  find  the  opening  of  the 
false  passage  with  ease.  It  lay  just  below  the  pin-point  orifice 
of  the  strictured  part  of  the  urethra,  and  it  appeared  as  a  bloody- 
edged  ragged  slit.  But  the  patient  called  out  almost  immedi- 
ately that  something  was  running  down  the  insides  of  his 
thighs,  and  I  then  became  aware  that  air  was  passing  freely 
through  the  opening  of  the  "false  passage"  and  escaping  into 
the  tissues  of  the  perineum.  There  was  no  doubt  that  the 
false  passage  was  very  extensive.  No  ill  results  ensued,  but  it 
is  easily  conceivable  that  damage  of  a  grave  description  can  be 
inflicted  by  unfiltered  air  passing  over  an  inflamed  surface  and 
opening  up  extensive  cellular  planes  in  the  thighs,  perineum 
and  pelvis."* 

The  accurate  localization  of  stricture  in  its  relative  position 
to  the  urethral  lumen  is  extremely  important.  The  reasons  for 
this  position  will  be  fully  explained  in  the  consideration  of  the 
operative  treatment  of  stricture  via  the  urethroscope. 

We  wish  here  to  call  attention  to  the  salient  points  in  the  use 
of  air-inflation  in  the  urethroscopic  diagnosis  of  stricture.  We 
believe  that  it  can  be  asserted  without  fear  of  contradiction  that 
the  urethroscopic  picture  of  stricture  presented  under  air- 
inflation  is  much  clearer  and  the  essential  detafls  much  more 
readily  recognized  than  under  ordinary  urethroscopy.  With  the 
distal  end  of  the  urethroscope  close  to  but  not  against  the  ante- 
rior face  of  the  stricture,  the  air-inflation  brings  the  stricture 
out  in  detail.     The  urethra  anterior  and  posterior  to  the  stric- 

*The  Urethroscope:     Its  Development  and  Its  Use.     William  R.  Fox,  Austral- 
asian Medical  Gazette,  October  20,  1906. 


URETHROSCOPY    OF    THE   DISEASED   URETHRA  1 97 

ture  is  dilated  and  the  irregular  lumen  of  the  urethra  at  the  point 
of  encroachment  of  the  infiltration  contrasts  markedly  with  the 
normal  lumen.  The  relative  position  of  the  stricture  to  the 
lumen,  its  extent  and  its  classification  from  a  clinical  standpoint 
and  the  presence  or  absence  of  other  strictures  in  its  neighbor- 
hood and  posterior  to  it,  are  points  which  are  clearly  demon- 
strable under  air-inflation.  Of  these  last  points,  the  first  is 
practically  the  only  one  which  can  be  definitely  determined  by 
ordinary  urethroscopy.  The  presence,  relative  location,  clin- 
ical character  and  extent  of  other  strictures  posterior  to  the  one 
immediately  under  observation  can  be  positively  diagnosed  by 
no  other  means  than  air-inflation  urethroscopy. 

Valves  and  Diverticula.  A.  Valves. — The  occurrence  of 
valves  in  the  urethra  has  usually  been  attributed  to  the  presence 
of  greatly  enlarged  Morgagni's  lacunae  or  lacunae  which,  during 
the  process  of  dilatation  for  chronic  urethritis,  have  become 
split.  This  view  is  not  supported  by  clinical  evidence  for  in 
many  cases  these  valves  are  located  on  the  inferior  wall. 

They  may  be  found  in  any  portion  of  the  urethra,  though  the 
region  just  behind  the  navicular  fossa,  the  bulbous  portion  and 
the  prostatic  portion  seem  to  be  the  locations  in  which  they  are 
most  generally  found.  Both  Segall  and  Schlagenhaufer  have 
reported  cases  of  fatally  obstructive  valvular  formation  in  the 
prostatic  portion  of  the  canal. 

The  position  which  these  valves  occupy  and  their  direction 
varies.  Valves  w^hich  are  formed  by  dilated  or  split  Morgagni's  I 
lacunae  always  occupy  the  superior  half  of  the  canal  and  have 
their  openings  directed  anteriorly.  They  cause  trouble  only 
by  reason  of  a  possible  obstruction  to  the  passage  of  instruments, 
or  by  becoming  the  seat  of  a  retained  infection. 

Other  valves  of  unknown  origin  are  occasionally  found  in 
the  urethra.  These  valves  may  occupy  any  part  of  the  circum- 
ference of  the  canal.  Their  openings  may  be  directed  either 
toward  the  meatus  or  the  bladder.  In  the  former  case,  in  the 
absence  of  infection,  they  rarely,  if  ever  give  rise  to  symptoms. 


iqS  cystoscopy  and  urethroscopy 

If  of  the  latter  form  the  symptoms  are  usually  obstructive  in 
character. 

Personally,  we  have  observed  two  cases  of  valvular  formation 
on  the  floor  of  the  urethra,  one  of  which  was  located  just  back 
of  the  glans  with  its  opening  directed  toward  the  meatus  while 
the  other  was  in  the  bulbous  cul-de-sac  with  its  opening  toward 
the  bladder.  The  former,  which  was  in  a  man  fifty-five  years  of 
age,  gave  rise  to  no  symptoms  and  was  discovered  accidentally 
by  means  of  the  urethroscope.  The  latter  case  was  in  a  young 
man  of  twenty-one  years  and  was  accompanied  by  slight 
dribbling. 

Seen  through  the  urethroscope  the  valves  formed  from  the 
lacunae  of  Morgagni  usually  present  simply  as  dilated  lacunar 
orifices.  The  opening  appears  as  a  slit  either  in  the  direction  of 
the  canal  or  placed  transversely  to  it.  The  orifice  is  ordinarily 
V-shaped,  the  point  of  the  V  being  placed  distally.  In  non- 
infected  valves  the  edges  of  the  orifice  appear  slightly  paler  than 
the  surrounding  mucosa  and  fall  closely  together.  In  cases  of 
infection  the  edges  become  decidedly  more  prominent  and  red- 
dened, taking  on  practically  the  same  modifications  which  char- 
acterize infections  of  lacunae  of  normal  size. 

Those  valves  which  do  not  originate  in  Morgagni' s  lacunae 
appear  as  transverse  or  V-shaped  slits.  These  valves  are  formed 
by  a  thin  covering  of  mucosa,  paler  than  that  surrounding  them. 
Their  dimensions  vary  greatly.  The  over-lying  thin  edge  is 
closely  in  contact  with  the  subjacent  mucosa.  The  orifice  in 
uninfected  cases  appears  as  a  thin  line  placed  transversely  to  the 
urethra.  On  the  mucosa  where  the  opening  is  V-shaped  the 
edges  may  simulate  the  normal  folds,  especially  in  the  bulbar 
portion,  giving  rise  to  an  error  in  diagnosis. 

The  diagnosis  is  not  difficult  in  those  valves  having  their 
orifices  directed  toward  the  meatus.  A  urethral  probe  may  be 
placed  under  the  overlying  edge  affording  a  ready  diagnosis. 
Better  still,  under  air-inflation,  the  air  is  forced  under  the  valve 


URETHROSCOPY   OF    THE   DISEASED    URETHRA  1 99 

causing  it  to  become  raised  and  its  presence  and  extent  can  thus 
be  diagnosed  with  certainty,  with  a  minimum  of  trauma. 

In  the  valves  having  their  orifices  directed  toward  the 
bladder  and  which  are  giving  rise  to  but  little  obstructive  symp- 
toms, the  diagnosis  may  prove  more  difficult.  In  the  case  which 
came  under  our  observation,  the  valve  was  in  the  bulbar  cul- 
de-sac  and  its  identity  could  not  be  established  by  ordinary 
urethroscopy.  Under  air-inflation,  the  air  was  refluxed  back 
from  the  obstruction  presented  by  the  compressor  and  lifted  up 
the  valve,  bringing  it  plainly  into  view  and  establishing  the  diag- 
nosis beyond  doubt.  We  should  strongly  suggest  the  use  of  air- 
inflation  in  the  diagnosis  of  this  variety  of  valvular  formation, 
believing  that  it  affords  a  more  certain  method  of  diagnosis. 

B.  Diverticula. — Diverticula  of  the  urethra  are  of  two  t>^es 
— those  due  to  a  congenital  absence  of  erectile  tissue  and  those 
due  to  a  gradual  dilatation  behind  acquired  stricture.  Both 
forms  are  practically  always  found  upon  the  floor  of  the  urethra. 

It  is  extremely  exceptional  to  be  able  to  observe  the  congeni- 
tal form  through  the  urethroscope  as  it  usually  becomes  thor- 
oughly recognizable  at  an  age  too  early  for  urethroscopy. 

The  latter  form  is  often  observed  in  strictured  urethrae  and, 
as  it  always  forms  back  of  fairly  small-calibered  strictures,  its 
detection  by  means  of  urethroscopy  necessitates  the  use  of  air- 
inflation. 

With  the  end  of  the  urethroscope  against  the  anterior  face  of 
the  stricture  the  air  balloons  the  urethra  back  of  it.  The  urethra 
is  seen  to  be  pouched  and  of  larger  than  normal  caliber.  This 
pouching  practically  always  takes  place  on  the  inferior  wall 
back  of  annular  stricture.  The  diverticulum  is  much  redder 
than  the  infiltrated  tissue  around  it,  and  the  pouching,  or  dip- 
ping in,  of  the  urethral  wall  is  characteristic. 

Tumors. — New-growths  of  the  urethra  with  the  possible 
exception  of  the  vascular  poh'pi,  or  caruncles,  found  in  the  female 
urethra,  are  comparatively  rare.  Papillomata,  both  sessile  and 
pedunculated,  fibrous,  fibro-myomatous,  fibro-myxomatous  and 


200  CYSTOSCOPY   AND    URETHROSCOPY 

vascular  polypi,  cysts  of  Cowper's  glands  and  of  the  prostatic 
utricle,  carcinomata  and  sarcomata  occur  in  frequency  in  about 
the  order  mentioned. 

(A)  Papillomata. — The  site  of  predilection  of  the  most  com- 
mon form  of  urethral  new-growth  is  at,  or  in  the  neighborhood  of, 
the  external  meatus,  though  papillomata  have  been  found 
throughout  the  entire  extent  of  the  urethra  and  may  even  invade 
the  bladder.  Oberlander,  Desgueir  (Soc.  beige  de  chir.,  Decem- 
ber 28,  1890)  and  Reboul  (Assoc,  franc,  d'urologie,  1896)  report 
cases  of  this  character.  For  the  first  description  of  papillomata 
of  the  deeper  portions  of  the  urethra  we  are  indebted  to  Vajda 
(Wiener  medic.  Wochenschrift,  1882).  Similar  cases  are  cited 
by  him,  the  reports  emanating  from  Morgagni,  Rokitansky, 
Hunter,  Tarnowsky,  Dittel  and  others.  Since  that  time  there 
have  been  numerous  cases  reported  by  various  observers,  not- 
ably Rosenthal,  Kollmann  and  Oberlander,  in  Germany,  and 
Klotz,  in  this  country. 

While  recognizing  the  fact  that  urethral  papillomata  are  not 
invariably  preceded  by  a  chronic  urethritis,  Oberlander  (Sa- 
jous's  Annual,  1888,  II,  212,  from  Vierteljahresschrift  fiir 
Derm,  und  Syph.)  has  described  a  form  of  papillary  over- 
growth— "urethritis  papillomatosa " — which  takes  place  upon 
the  areas  of  infiltration  found  in  chronic  urethritis.  Bruggs 
(Gaz.  hebd.  de  Montpelier,  1890,  No.  5,  p.  58)  reports  a  charac- 
teristic case  of  this  form  of  urethritis.  It  may  be  stated  as 
practically  axiomatic  that  those  papillomata  which  originate 
back  of  the  navicular,  fossa  arise  from,  but  two  causes — chronic 
gonorrhea  and  syphilis.  Legeueu's  investigations  (Traite  de 
Chirurgie,  tome  IX)  bear  out  this  contention,  and  Halle  and 
Wassermann  have  given  a  most  excellent  description  of  those 
papillomata  which  arise  from  the  extreme  degree  of  hard  infil- 
tration, while  papillomata  originating  in  the  lesser  degrees  of 
infiltration  have  been  thoroughly  studied  by  Griinfeld  (Die 
Endoscopic  der  Harnrohre  und  Blase).  Cases  of  a  similar 
character  have  been  reported  by  numerous  observers,  notably 


URETHROSCOPY    OF    THE    DISEASED    URETHRA  20I 

Bryant  (Med.  Chir.  Trans.,  Vol.  LXXVI,  p.  191),  Klotz  (N.  Y. 
Med.  Jour.,  Jan.  26,  1895),  Goldenberg  (N.  Y.  Med.  Jour.,  Nov., 
1898,  p.  600),  Eversole  (St.  Louis  Polyclinic,  Aug.  5,  1889)  and 
Briggs  (Boston  Med.  and  Surg.  Jour.,  Oct.  24,  1889). 

Endoscopically  considered,  papillomata  present  themselves 
either  singly  or  in  groups,  or  "nests"  (Rosenthal,  Berliner  klin. 
Wochenschrift,  1884,  No.  23).  Single  papillomata,  unassociated 
with  multiple  growths  in  other  parts  of  the  urethra,  are  of  extreme 
rarity.  They  are  almost  invariably  found  in  that  portion  of  the 
urethra  lying  between  the  peno-scrotal  junction  and  the  anterior 
layer  of  the  triangular  ligament,  apparently  springing  from  iso- 
lated papillae.  According  to  Henle  (Handbuch  der  Systemat. 
Anatomic,  Vol.  II,  p.  433),  papillae  in  the  male  urethra  are  par- 
ticularly abundant  in  the  region  covered  with  stratified  pavement 
epithelium,  an  extent  of  from  one  to  four  centimeters  from  the 
meatus.  Back  of  this,  single,  isolated  papillae  are  found  and 
it  is  from  these  scattered  papillae  that  the  single  papillomata 
arise. 

Multiple  papillomata  practically  always  originate  at,  or  in 
the  neighborhood  of,  the  external  meatus  and  are  usually  asso- 
ciated wdth  similar  papillary  exuberances  on  the  glans  and 
prepuce  in  the  male  and  vulva  in  the  female.  They  have  a 
tendency  to  extend  along  the  inferior  wall,  though  no  part  of  the 
urethral  circumference  is  exempt,  and  the  entire  extent  of  the 
urethra  may  be  invaded. 

Through  the  urethroscope  papillomata  have  the  appearance 
of  roughened  warty  excrescences  of  a  glistening  pale  pink  color. 
They  resemble  closely  the  verrucae  acuminata,  exhibiting  the 
same  differences  in  shape  and  extent.  In  the  grouped,  or  nested, 
papillomata  the  base  of  the  growth  is  broader  than  in  the  single 
isolated  growth.  The  latter  occasionally  appear  as  thin  delicate 
fibrillae.  Both  forms  are  usually  found  when  the  growths 
invade  the  urethra  to  any  extent. 

The  urethroscopic  appearance  of  these  growths  is  so  typical 
that  it  is  hardly  possible  for  a  mistake  in  diagnosis  to  occur.     The 


202  CYSTOSCOPY   AND   UEETHROSCOPY 

fact  that  they  are  readily  rubbed  off  their  site  of  attachment 
leaving  a  freely  bleeding  base  makes  the  diagnosis  certain. 

In  the  urethroscopic  examination  of  papillomata,  the  readi- 
ness with  which  they  may  be  separated  from  their  site  of  attach- 
ment and  the  tendency  of  any  laceration  of  these  growths  to 
produce  hemorrhage  which  will  make  the  diagnosis  difficult  must 
be  kept  in  mind.  In  the  accurate  diagnosis  of  the  presence  and 
extent  of  urethral  papillomata,  air-inflation  urethroscopy  is 
absolutely  essential.  By  means  of  air-inflation  the  tendency 
to  tearing  the  growths  is  reduced  to  a  minimum  and  their  charac- 
ter and  extent  may  be  easily  determined. 

(B)  Polypi. — The  term  polyp  as  applied  to  certain  new- 
growths  in  the  urethra  has  been  so  varied  in  its  application  as  to 
cause  much  confusion  in  the  classification  of  tumors  of  the 
urethra.  Legeueu  (loc.  cit.) ,  Janet  (Cinq  cas  de  pol}^es  uretraux, 
Assoc,  franc,  d'  urologie,  2nd  session,  Comptes  rendus,  Paris, 
1898,  p.  402)  and  others  have  included  papillomata  in  their 
classification  of  polypi,  serving  further  to  confuse  the  literature. 
Janet  divides  polypi  into  two  classes:  (i)  Worm-like,  single 
growths  found  in  the  region  of  the  bulb  and  (2)  papillomatous, 
sessile  growths  disseminated  throughout  the  urethra.  The 
inclusion  of  the  latter  under  the  head  of  polypi  seems  to  us  to  be 
manifestly  incorrect. 

In  order  to  obviate  this  confusion  in  classification  we  consider 
it  more  logical  to  include  under  the  clinical  term  of  polypi  those 
growths  which  resemble  clinically  the  tumors  found  elsewhere 
which  have  been  consistently  classified  as  polyps.  Under  this 
heading  come  fibromata,  fibro-myxomata,  fibro-myomata  and 
vascular  polypi,  the  caruncles  of  the  female  urethra.  '  Fibromata 
are  rare  and  true  myxomata  are  never  found.  We  do  not  include 
under  the  heading  of  polypi  those  glandular  hypertrophies 
occurring  as  an  accompaniment  of  chronic  gonorrheal  urethritis. 
They  have  been  classified  as  polypi  by  several  authors, 
notably  Legeueu,  who  considers  them  to  be  the  purest  type  of 
polyp,  and  insists  upon  their  constant  pedunculation. 


URETHROSCOPY   OF    THE   DISEASED   URETHRA  203 

(A)  Vascular  Polypi. — Vascular  pol}^i,  to  which  the  terms 
urethral  caruncles  and  angiomata  have  been  applied,  are  found 
with  great  constancy  in  the  female  urethra  but  are  exceptionally 
rare  in  the  male,  only  a  few  instances  being  recorded. 

According  to  Pozzi,  this  form  of  urethral  new-growth  in  the 
female  results  from  the  retention  of  erectile  tissue  which  normally 
belongs  to  the  male,  and  their  growth  is  dependent  upon  some 
local  irritation.  The  growth  is  composed  of  dilated  capillaries 
intermixed  with  connective  tissue  and  has  a  covering  of  stratified 
epithelium.  It  has  a  plentiful  nerve  supply.  The  vascular 
pohpi  must  not  be  confounded  with  the  varices  occurring  in 
the  female  urethra,  from  which  they  difi'er  both  histologically 
and  clinically. 

They  are  found  most  commonly  at  the  middle  period  of  life, 
though  Giraldes  observed  a  case  in  an  infant  of  three  years  and 
Trelat  has  operated  for  this  condition  on  a  woman  of  seventy- 
five  years. 

In  the  female  they  present  themselves,  as  a  rule,  at  the 
meatus  externus  or  just  within  the  urethra  on  the  floor.  In  the 
cases  recorded  as  occurring  in  the  male,  the  polypi  were  found 
just  within  the  meatus  or  in  the  navicular  fossa  and  resembled, 
in  all  clinical  peculiarities,  the  caruncles  found  in  the  female. 

They  appear  as  bright-red,  succulent  looking  growths,  having 
a  distinct  pedicle  and  are  exquisitely  sensitive.  While  ordinarily 
single  they  are  very  often  multiple. 

The  urethroscope  is  seldom  called  upon  in  the  diagnosis  of 
vascular  polypi  on  account  of  their  location.  Their  extreme 
sensitiveness  combined  with  their  bright  red  appearance  serves 
to  differentiate  them  from  the  other  forms  of  urethral  polypi. 

(B)  Fibromata,  Fibro-m3rxomata  and  Fibro-myomata. — 
These  three  varieties  of  urethral  new-growth  resemble  each  other 
so  closely  clinically  that  it  is  practically  impossible  to  make  a 
differential  diagnosis  until  the  tumors  are  examined  histologic- 
ally. On  account  of  the  lack  of  clinical  individuality  we  shall 
consider  them  collectively.     True  fibromata  are  extremely  rare, 


204  CYSTOSCOPY   AND   URETHROSCOPY 

the  mixed  types,  fibro-myxomata  and  fibro-myomata,  being  most 
commonly  found.  They  present  themselves,  as  a  rule,  in  the 
adult  female,  Legeueu  absolutely  excluding  their  presence  in  the 
male,  though  this  stand  is  refuted  by  numerous  observers. 

The  fibro-myxomata  develop  in  areas  of  infiltration,  usually 
the  result  of  chronic  urethritis.  Fibro-myomata  develop  at  the 
expense  of  the  fibro-muscular  elements  and,  in  their  incipiency, 
are  not  intraurethral  growths,  but  in  the  course  of  their  develop- 
ment project  into  the  urethral  lumen.  (Dubar,  Notes  sur  un 
volumineux  polype  de  I'uretre  chez  la  femme.  Bull.  med.  du 
Nord,  t.  XXVIII,  p.  4SI-) 

In  the  male,  the  mixed  forms  have  been  reported  by  various 
observers  as  occurring  in  the  different  anatomical  divisions  of 
the  canal,  the  bulbous  portion  seeming  to  be  the  most  common 
site.  The  predilection  of  these  polypi  for  this  location  is  borne 
out  by  the  observations  of  Janet,  Klotz  and  others  and  is  in 
accord  with  our  own  clinical  experience.  Klotz  reports  one 
case  as  springing  from  the  membranous  urethra,  a  most  unusual 
location. 

Well-authenticated  observations  of  true  fibromata  occur- 
ring in  the  male  urethra  are  exceptionally  rare,  and  in  all 
of  the  reported  instances  the  growths  were  located  in  the  pros- 
tatic urethra  and  had  their  site  of  attachment  in  the  immediate 
neighborhood  of  the  ejaculatory  ducts.  They  were  almost 
invariably  single.  We  have  observed  postmortem  a  case  of 
multiple  fibromata  in  the  prostatic  portion  of  the  canal.  In 
this  case  there  were  six  distinct  polypi  scattered  over  the  inferior 
wall  and  sides  of  the  prostatic  urethra. 

In  the  female,  as  in  the  male,  the  growths  may  spring  from 
any  point  in  the  urethra  and  on  account  of  their  pedunculation, 
which  is  sometimes  extreme,  may  present  at  the  external  meatus 
though  their  site  of  attachment  may  be  a  considerable  distance 
within  the  urethra.  Their  point  of  origin  is  usually  at  the  level 
of  the  posterior  wall  in  the  urethro- vaginal  partition. 

Endoscopically,  these  growths  appear  as  smooth,  rounded 


URETHROSCOPY   OF    THE   DISEASED   URETHRA  205 

polypi  having  a  distinct  pedicle  or  stem,  the  pedunculation  being 
more  pronounced  in  the  fibro-myxomata  and  fibromata.     The 
growth  has  a  tendency  to  stand  out  fairly  prominently  exhibit-i 
ing  a  stiffness,  as  it  were,  of  the  pedicle. 

Normally,  the  color  varies.  In  the  fibro-myomata  it  is 
practically  the  same  as  that  of  the  surrounding  healthy  mucosa. 
In  the  fibromata  and  fibro-myxomata,  the  coloring  is  paler, 
almost  sclerotic  in  the  latter.  In  the  diagnosis  of  these  growths 
their  possible  malignancy  must  be  taken  into  consideration. 
Both  sarcomata  and  carcinomata  may  present  as  pedicled 
growths  and  the  possibility  of  malignant  transformation  of 
essentially  benign  growths  must  not  be  overlooked.  Toupet, 
in  examining  Schwartz's  case  (Sem.  Med.,  1889),  found  in  the 
center  of  the  polyp  a  transitional  change  toward  malignancy. 

In  his  work  (Die  Endoskopie  der  Harnrohre  und  Blase) 
Griinfeld  has  noted  a  difficulty  in  recognizing  the  larger  worm- 
like polypi  on  account  of  the  growths  falling  closely  against  the 
walls  on  the  withdrawal  of  the  urethroscope  and  simulating 
the  natural  folds.  To  prevent  this,  he  has  suggested  that  the 
urethra  be  inspected  while  inserting  the  urethroscope,  thus 
unrolling  the  growth  into  the  lumen  of  the  tube. 

We  cannot  conceive  the  possibility  of  such  an  error  in 
diagnosis  at  the  hands  of  a  skilled  and  careful  urethroscopist, 
and  even  admitting  the  possibility  under  ordinary  urethroscopy, 
such  an  error  could  not  arise  under  the  use  of  air-inflation.  We 
cannot  commend  the  procedure  recommended  by  Griinfeld  on 
account  of  its  being  so  productive  of  trauma. 

Varices. — The  occurrence  of  varices  in  the  female  urethra  is 
not  uncommon  but  their  existence  in  the  male  urethra  is  of 
exceptional  rarity,  their  being  but  two  cases  whose  authenticity 
seems  established,  those  of  Klotz  (N.  Y.  Med.  Journ.,  Jan.  26, 
1895)  and  Young  reported  by  Fowler  (The  Johns  Hopkins 
Hospital  Reports,  Vol.  XIII,  p.  91).  The  urethroscopic  descrip- 
tions of  these  cases  are  so  interesting  that  we  give  them  in 
extenso. 


206  CYSTOSCOPY   AND    URETHROSCOPY 

Klotz's  Case. — "The  protruding  portion  of  the  mucous 
membrane  was  found  to  be  of  a  smooth  surface  and  a  dark 
bluish  color,  of  the  shape  and  size  of  a  coffee  bean,  sharply  defined 
at  the  base  from  the  dark  pink  surrounding  portions.  The 
tumor  was  soft  and  easily  yielded  to  the  pressure  of  the  tube, 
although  on  introduction  it  seemed  to  offer  a  slight  resistance. 
On  close  inspection  within  the  tumor  a  number  of  separate  cords, 
separated  by  yellowish  white  lines  resembling  the  rings  of  a  coil, 
could  be  distinguished,  apparently  representing  dilated  blood 
vessels,  and  imparting  to  the  whole  mass  the  character  of  a 
cavernous  angioma." 

Young's  Case. — "  Urethroscopic  examination  by  Dr.  Young. 
No.  26  Otis  tube  was  passed  into  the  prostatic  urethra,  but 
it  was  impossible  to  introduce  it  as  far  as  the  verumontanum. 
The  anterior  portion  of  the  prostatic  urethra  which  was  examined 
showed  nothing  particularly  abnormal.  The  membranous  ure- 
thra was  also  about  normal.  As  soon  as  the  bulbous  urethra 
was  reached,  in  drawing  the  urethroscope  outward,  the  picture 
was  at  once  remarkably  abnormal.  Several  large,  deep-red, 
irregular  masses  projected  into  the  lumen,  and  between  them 
were  depressions  of  a  dull  gray  color  which  suggested  ulceration 
or  old  scars,  but  were  probably  not.  This  condition  was  present 
in  the  entire  anterior  urethra.  As  the  instrument  was  drawn 
slowly  out,  a  succession  of  irregular,  rounded,  deep  red  masses 
projected  over  the  end  of  the  endoscope;  these  were  apparently 
covered  by  healthy  mucous  membrane,  and  between  them  were 
irregular  depressions  of  grayish  color,  supposed  at  first  to  be 
ulcers,  but  no  exudation  could  be  obtained  from  them,  and  prob- 
ing did  not  cause  any  hemorrhage,  so  that  it  was  evident  that 
they  were  not  ulcers.  The  rounded  deep  masses  which  were 
scattered  over  the  mucous  membrane  were  evidently  dilated 
blood  vessels.  There  were  no  ulcerations  to  be  seen,  and  no 
ruptured  vessels  or  definite  points  of  active  hemorrhage,  though 
blood  constantly  appeared  in  the  endoscopic  field." 

Varices  of   the  female  urethra  usually  present  at  or  im- 


UEETHROSCOPY    OF    THE    DISEASED    URETHRA  207 

mediately  behind  the  meatus  externus.  They  may  attain  a  rela- 
tively large  size.  On  account  of  the  accessibility  and  their  hemor- 
rhoidal appearance,  their  urethroscopic  description  is  unnecessary. 

Carcinoma. — Primary  carcinoma  of  the  urethra  is  an  ex- 
tremely rare  affection,  especially  so  in  the  male.  At  different/ 
intervals  various  observers  have  collected  the  literature  bearing' 
on  the  subject  so  that  we  may  say  that  carcinoma,  while  of 
extreme  rarity,  is  probably  the  most  thoroughly  studied  of  all 
of  the  new-growths  of  the  urethra.  The  combined  investigations 
of  latter-day  observers,  notably  Basil,  Hall  (Ann.  of  Surgery, 
March,  1904)  and  M.  Hartmann  (Travaux  de  Chirurgie,  1906) 
show  but  twenty-seven  proved  cases  of  carcinoma  of  the  male 
urethra,  and  thirty-six  in  the  female.  To  these  cases  we  wish 
to  add  two  observations,  one  by  Dr.  Frank  J.  Hall,  a  squamous- 
cell  cancer  of  the  female  urethra  and  the  other  by  Dr.  J.  Block 
and  ourselves,  a  carcinoma  of  the  bulbous  urethra. 

The  first  case  reported  is  that  of  Thiaudiere,  in  1834.  This 
case  is  rejected  by  both  Kaufmann  and  Hall  though  in  all 
probability  the  growth  was  a  carcinoma. 

The  first  authentic  case  is  that  reported  by  Hutchinson 
(Trans.  Path.  Soc,  London,  Vol.  XIH,  p.  167,  in  1861). 
Since  that  time  there  have  been  a  number  of  theses  on  the  subject 
by  Thiersch,  Billroth,  Poncet,  Guyon  and  Guiard,  Salzer  and 
Griinfeld,  Griffith,  Czerny  and  Witzenhausen,  Carey,  Beck, 
Oberlander,  Albarran,  Hall,  Hartmann  and  others.  A  full 
review  of  the  literature,  which  is  fairly  voluminous,  would  be 
out  of  place  in  a  work  of  this  character.  , 

Practically   all   of   the  reported   cases  were   squamous-cell   I 
carcinoma.     Kocher's  case  (Deutsche  Chirurgie,  1884)  was  partly 
a  t>pical  glandular  carcinoma  and  partly  a  cylindroma.     The 
case  of  W.  Knoll  (Deutsche  Zeitschriftfiir  Chirurgie,  1906)  was  an 
adeno-carcinoma. 

The  site  of  predilection  of  carcinoma  in  the  male  urethra  is 
in  the  bulbar  portion.  In  the  cases  of  Thiaudiere,  Hutchinson, 
and  Buday,  the  growth  was  located  just  posterior  to  the  glans. 


2o8  CYSTOSCOPY   AND   URETHROSCOPY 

In  Billroth's  case,  the  cancer  began  in  the  mid-pendulous  portion, 
while  in  Griinfeld's  case,  the  prostatic  urethra  was  the  point  of 
origin.  Hartmann  is  of  the  opinion  that  the  tumor  in  Griin- 
feld's case  originated  in  the  prostate  and  that  the  urethra  became 
involved  secondarily. 

In  the  majority  of  cases  in  the  male,  the  growth  was  preceded 
and  accompanied  by  gonorrheal  stricture,  though  some  cases 
presented  no  history  of  gonorrhea.  Hartmann  thinks,  however, 
that  gonorrheal  stricture  occurs  with  sufficient  frequency  to  be 
considered  as  a  factor  in  the  etiology. 

Urethrorrhagia  is  considered  by  Beck  to  be  a  fairly  common 
symptom  though  in  quite  a  considerable  proportion  of  the  cases 
there  was  no  hemorrhage  from  the  urethra.  In  the  cases  of 
Beck,  Guyon  and  Guiard  and  of  Griinfeld,  hemorrhage  was  a 
prominent  symptom.  In  the  case  observed  by  Dr.  Block  and 
ourselves,  hemorrhage  from  the  meatus,  occurring  independently 
of  micturition,  was  one  of  the  earliest  symptoms. 

Carcinoma  of  the  urethra  has  been  observed  but  three  times 
via  the  urethroscope — by  Griinfeld,  1885,  Oberlander,  1893, 
and  Beck,  1890.  In  Oberlander's  case  the  diagnosis  was  made 
by  means  of  urethroscopy  and  later  confirmed. 

The  observations  of  these  three  authors  are  of  such  interest 
as  to  justify  a  detailed  description. 

Griinfeld's  Case. — Urethroscopy  with  a  straight  tube.  On 
inserting  the  tube  to  a  depth  of  twelve  centimeters,  a  small 
polypoid  growth  was  encountered,  implanted  with  a  short 
pedicle.  Four  centimeters  further  back,  a  second  growth 
flattened  in  shape  was  found.     Their  color  was  whitish  yellow. 

The  urethral  mucosa  of  the  entire  posterior  urethra  had  an 
abnormal  appearance.  On  inserting  the  tube  to  the  verumon- 
tanum  a  narrow,  horseshoe-shaped  band  of  congested  mucosa 
was  encountered  having  its  convexity  at  the  right.  The  re- 
mainder of  the  urethroscopic  field  was  filled  by  a  tumor  lying 
transversely.  One-half  of  this  growth  was  of  a  pale  rose  color; 
the  other  half  was  grayish. 


URETHROSCOPY   OF    THE    DISEASED   URETHRA  209 

The  surface  of  the  growth,  which  bulged  into  the  lumen  of 
the  tube,  exhibited  a  furrowed  appearance  with  small  red 
excavations.  Dilated  blood  vessels  were  also  noted.  On  slight 
withdrawal  of  the  tube  a  thin  septum,  running  horizontally,  was 
noticed.  The  mucosa  above  this  septum  was  deeply  livid  and 
bled  on  the  slightest  touch.  Below,  the  mucosa  was  ulcerated. 
By  manipulation  the  tumor  could  be  raised,  disclosing  the  ulcer- 
ated mucosa.  On  the  inferior  surface  of  the  tumor,  two  faceted 
appearing  spots  were  observed.     The  growth  was  carcinomatous. 

Oberlander's  Case. — Urethroscopic  tube  No.  27  inserted  to 
the  extremity  of  the  bulb.  In  the  inferior  half  of  the  field  was 
seen  a  semilunar  pale  cicatrix.  The  surrounding  mucosa  was 
grayish  and  sclerotic  looking.  The  entire  extent  of  the  mucosa, 
almost  to  the  region  of  the  navicular  fossa,  presented  a  similar 
sclerotic  appearance,  with  several  cicatrices.  At  some  points  a 
plicated  appearance  of  the  mucosa  was  noted.  There  was  a 
glandular  urethritis. 

Behind  and  above  the  semilunar  cicatrix  a  growth  was  ob- 
served. By  drawing  the  penis  forward  and  pushing  in  the  tube 
the  growth  could  be  made  to  present  in  the  lumen  of  the  tube. 
The  growth  was  distinctly  raspberry-like,  being  irregularly 
mammillated  and  presenting  a  bright  red  appearance. 

The  tumor  was  a  squamous-cell  carcinoma.  In  Beck's  case 
the  growth  was  found  in  the  neighborhood  of  a  stricture.  The 
tumor  presented  as  a  papillary  prominence  on  the  superior  wall 
and  toward  the  right  side  of  the  urethra.  The  growth  was  a 
freely  bleeding  one.     It  was  a  squamous-cell  carcinoma. 

The  value  of  the  urethroscope  in  the  early  diagnosis  of  ure- 
thral cancer  cannot  be  overestimated.  A  review  of  the  litera- 
ture relative  to  carcinoma  of  the  urethra  discloses  the  fact  that 
in  the  vast  majority  of  the  cases  the  growth  had  advanced  to 
the  point  of  urinary  extravasation  and  fistula  before  the  diagno- 
sis was  made.  It  will  be  noted  in  the  record  of  the  twenty-one 
microscopically  confirmed  cases,  recorded  by  Basil  Hall, 
that  the  case  of  Oberlander's  is  the  only  one  in  which  the  growth 
14 


2IO  CYSTOSCOPY   AND    URETHROSCOPY 

had  not  recurred  within  one  year  from  the  first  operation.  In 
Oberlander's  case  there  was  no  recurrence  twenty-one  months 
after  an  operation  which  was  fairly  conservative — a  resection  of 
the  urethra.  Beck's  case  was  lost  sight  of.  In  Carey's  case, 
in  which  total  emasculation  was  done,  there  was  no  recurrence 
in  ten  months  and  in  one  of  Montgomery's  cases,  there  was  no 
recurrence  four  months  subsequent  to  an  amputation  of  the 
penis.  In  all  of  the  other  cases,  recurrence  was  noted  within 
six  months. 

While  from  the  standpoint  of  urethroscopy  we  have  but 
meager  data  at  our  command  on  which  to  base  a  diagnosis,  we 
may  safely  consider  any  easily  bleeding,  fungating  or  raspberry- 
like growth  in  the  urethra  of  a  man  who  has  attained  the  age 
of  forty  years  to  be  under  suspicion.  A  small  piece  removed  via 
the  urethroscope  is  sufficient  for  the  purpose  of  an  exact  micro- 
scopic diagnosis.  Under  such  diagnosis,  early  operation  is 
possible  with  a  proportionately  favorable  prognosis. 

Sarcoma  of  the  Urethra. — Of  all  new-growths  found  in  the 
urethra,  sarcoma  is  most  uncommon,  there  being  but  few 
reported  instances.  To  Hoening  (Berlin  klin.  Wochenschrift, 
1869,  p.  55)  belongs  the  credit  for  the  first  reported  case.  Rizzoli 
(Jour,  de  med.  de  Bruxelles,  1875),  Tillaux  (Annales  de  gynecolo- 
gic, 1889),  Buttner  (Zeitschrift  fiir  Geb.  und  Gynaek.,  Bd. 
XVIII,  p.  122),  Ehrendorfer  (Centralblatt  fiir  Gynaek.,  1892), 
Lejars  (Lecons  de  chirurgie),  and  Albarran  have  all  reported  well 
authenticated  cases  of  fibro-sarcoma.  Hall  and  Frick  (Jour. 
A.  M.  A.,  June  23,  1906)  record  a  case  of  melanotic  sarcoma 
which  they  assume  from  the  postmortem  findings  must  have 
originated  in  the  urethra.  The  case  is  unique  but  the  clinical 
evidence  is  well  supported.  In  the  Annals  of  Surgery  for  March 
191 2,  page  416,  one  of  us  (Mark)  reports  a  case  of  primary  sar- 
coma of  the  male  urethra  which  is  of  sufficient  interest  to  merit  a 
detailed  report.     The  patient  was  24  years  of  age. 

The  urethroscopic  examination  follows:  No.  24  F.  tube  met 
obstruction  just  posterior  to  the  corona.     Under  air-inflation 


URETHROSCOPY   OF    THE    DISEASED    URETHRA  211 

very  pale  pol}poid  masses,  irregular  in  outline  were  observed, 
springing  from  the  entire  urethral  circumference.  Using  the 
urethroscopic  tube  as  a  curette  these  masses  were  removed  with 
great  difficulty  as  far  back  as  the  scrotal  urethra.  On  account 
of  the  bleeding  and  the  duration  of  the  operative  procedure  it 
was  deemed  advisable  to  postpone  any  further  measures.  The 
masses  thus  removed  were  left  at  the  hospital  for  pathological 
examination  which  was  somehow  neglected.  Six  days  later  the 
work  was  taken  up  where  it  had  been  left  off  and  utilizing  the 
same  procedure  as  at  the  former  operation,  the  remaining 
growths,  or  portion  of  the  growth,  were  removed  back  to  the 
anterior  layer  of  the  triangular  ligament, 

A  cystoscope  was  now  introduced  without  difficulty  and 
examination  revealed  a  high-grade  cystitis  but  no  e\ddence  of 
new  growth.     The  bladder  capacity  was  much  diminished. 

The  specimens  removed  were  submitted  to  Dr.  Frank  J. 
Hall  whose  report  follows :  "  Gross  specimen  consists  of  a  number 
of  whitish  soft  fragments.  Section  shows  sarcoma  poor  in 
blood  vessels  with  small  amount  of  stroma.  The  cells  are  of 
the  large  round  type,  with  a  suggestion  of  polymorphus  cells 
with  vesicular  nuclei  and  pinkish  staining  cytoplasm.  (Frozen 
section,  H.  &  E.  Stain)." 

Legueu  makes  the  statement,  based  on  his  investigations, 
that  sarcoma  occurs  exclusively  in  the  adult  female.  In  the 
case  reported  by  Hall  and  Frick,  the  patient  was  a  male,  thirty- 
three  years  of  age. 

Fibro-sarcomata  of  the  urethra  pursue  the  same  indolent 
course  that  characterizes  their  growth  in  other  parts  of  the  body. 
Their  appearance  is  in  no  way  tjqDical  and  their  clinical  differ- 
ential diagnosis  from  fibromata  is  almost  impossible. 

On  account  of  their  appearing  almost  exclusively  in  the 
female,  their  large  size  and  the  ready  diagnosis  of  their  presence 
by  ordinary  methods  of  clinical  investigation  the  use  of  the  ure- 
throscope is  never  demanded.  We  ha\e  included  mention  of 
them  in  this  section  merely  for  the  sake  of  completeness. 


212  CYSTOSCOPY   AND    URETHROSCOPY 

Urethral  Tuberculosis. — Tuberculosis  of  the  urethra  is  prac- 
tically always  secondary  to  lesions  of  the  upper  urinary  tract 
or  adnexa,  there  being  absolutely  no  convincing  evidence  in 
support  of  the  few  reported  cases  of  so-called  primary  urethral 
tuberculosis.  Thisstatementis  supported  by  the  investigations 
of  Hogge  (Ann.  des  malad  des  Organes  Genito-urinaires,  1901, 
Vol.  XIX,  p.  1 491)  who  makes  the  statement  that  there  is  abso- 
lutely no  recorded  case  of  primary  urethral  tuberculosis. 

Kraske  believes  that  it  does  occur  and  Baumgarten,  cited 
by  Ahrens  (Beitrage  zur  Klin.  Chirurgie,  1891-92,  Vol.  VIII,  p. 
312)  has  produced  experimentally  typical  tuberculous  lesions  in 
the  urethra  of  a  buck  rabbit  by  direct  inoculation,  thus  demon- 
strating the  possibility  of  the  occurrence  of  primary  urethral 
tuberculosis,  though  similar  experiments  by  Blandini  (Annales 
des  mal.  des  Org.  Genito-urinaires,  1901,  Vol.  XIX,  p.  1491) 
failed  signally  in  this  respect.  ,  There  have  been  a  few  cases 
reported  in  which  the  tuberculous  lesions  of  the  urethra  v/ere 
secondary  to  a  tuberculosis  of  the  glans  penis.  In  the  cases  of 
Kraske  (Centralbl.  fur  Chirurgie,  1888,  Vol.  XV,  p.  889),  Poncet 
(Abstract  Central,  fiir.  Krank.  der  Harn.  und  Sex. -Org.,  1893, 
Vol.  IV,  512)  and  Hartmann  (H.  Hartmann,  Travaux  de  Chi- 
rurgie Anatomo-Clinique,  p.  278),  the  extension  was  by  perfora- 
tion, while  in  Ehrmann's  case  the  disease  extended  to  the  urethra 
via  the  meatus.  In  the  case  reported  by  Hartmann,  the  growth 
simulated  closely  a  neoplasm. 

The  conclusions  of  different  investigators  as  to  the  relative 
frequency  of  urethral  tuberculosis  are  greatly  at  variance.  From 
the  combined  investigations  of  Steinthal,  Krzywicki  and  Pavel 
in  433  cases  of  urogenital  tuberculosis  (Ahrens,  loc.  cit.)  there 
wxre  noted  but  eighteen  instances  of  urethral  involvement — 
slightly  over  40  per  cent.  In  the  investigations  of  Halle  and 
Motz  (Annales  des  mal.  des  Organes  Genito-urinaires,  Dec.  i  and 
15,  1902)  which  covered  a  series  of  over  160  cases  of  genito- 
urinary tuberculosis  observed  in  the  Hopital  Necker,  urethral 
involvement  was  noted  in  twelve  instances. 


URETHROSCOPY   OF    THE   DISEASED    URETHRA  213 

Urethral  tuberculosis  is  found  with  much  greater  frequency 
in  men,  Ahrens  being  able  to  find  but  four  recorded  instances 
of  its  occurrence  in  women.  ("Die  Tuberculose  der  Harnrohre," 
Beitrage  zur  klinischen  Chirurgie,  Vol.  VIII,  p.  312).  It  appears 
most  commonly  during  the  time  of  greatest  sexual  activity, 
i.e.,  between  the  ages  of  twenty  and  thirty. 

In  the  vast  majority  of  instances  of  tuberculosis  of  the  ure- 
thra, the  disease  is  confined  to  that  part  of  the  canal  lying 
posterior  to  the  triangular  ligament  and  is  so  intimately  asso- 
ciated with  lesions  in  the  bladder  and  adnexa  that  it  requires  no\ 
consideration  as  a  clinical  entity.  From  the  standpoint  of  the 
urethroscopist,  it  becomes  of  interest  only  when  it  attacks  the 
anterior  urethra  and  we  shall  confine  ourselves  to  the  considera- 
tion of  anterior  involvement.  We  shall  exclude  peri-urethral 
tuberculosis  and  that  form  of  the  disease  attacking  Cowper's 
glands,  minutely  studied  by  Englisch  (Allg.  Wien.  med.  Zeit- 
schrift,  1891,  p.  2). 

The  lesions  of  the  mucosa  present  as  two  clinical  forms,  tuber- 
cles and  ulcers,  most  commonly  the  latter .  Ulceration  is  simply 
the  advanced  stage  of  the  tubercle  and  its  more  frequent  obser- 
vaiton  is  dependent  upon  the  lack  of  symptoms  which  accompany 
the  earlier  manifestation  of  the  disease,  i.e.,  the  tubercle. 

The  urethroscopic  picture  is  rather  characteristic.  The 
tubercle  appears  as  a  yellowish  or  grayish  spot  in  the  midst  of  a 
zone  of  bright  red  infiltration.  In  the  very  early  stages  of  the 
lesion,  it  is  often  impossible  to  recognize  the  presence  of  the 
tubercle  through  the  urethroscope  on  account  of  its  minute  size. 
It  may  attain  the  dimensions  of  a  pea,  as  in  the  case  observed  by 
Michaut  (Bull.  Soc.  Anat.,  1887,  p.  103).  The  reddish  periphery 
is  fairly  regular  while  the  tubercle,  which  is  raised  above  the  sur- 
rounding zone  of  infiltration,  is  distinctly  so.  Later,  in  the 
ulcerative  stage,  the  zone  of  surrounding  red  loses  its  regularity 
of  outline. 

The  tubercle,  which  in  the  early  stages  of  disintegration, 
closely  resembles  a  chancre,  becomes  punched  out  and  ragged 


214  CYSTOSCOPY   AND   URETHROSCOPY 

looking  and  evinces  a  tendency  toward  phagedena.  This  latter 
tendency  is  more  marked  in,  and  in  fact,  may  be  almost  wholly 
dependent  upon,  a  diffuse  preulcerative  infiltration,  to  which, 
in  greatly  marked  cases,  the  term  "diffuse  caseous  infiltration" 
has  been  applied. 

The  lesions  are  practically  always  observed  to  begin  in  the 
bulbar  portion  and  to  extend  in  the  direction  of  the  meatus. 
In  the  case  reported  by  Kidd  (Trans.  Path.  Soc,  London,  Vol. 
XXXIX,  p.  185)  the  lesions  became  markedly  modified  as  they 
approached  the  meatus. 

Apparent  calcification  of  tuberculous  deposits  in  urethral 
tuberculosis  has  been  observed  by  Berard  and  Trillat  (Le  Bull. 
Medicale,  Vol.  XV,  p.  737).  The  patient  was  a  child  and  no 
satisfactory  examination  was  made,  though,  in  all  probability, 
there  was  calcification  of  a  periurethral  tuberculosis.  Chute 
(Boston  Med.  and  Surg.  Jour.,  Oct.  i,  1903,  p.  361)  has  reported 
a  case  of  calcification  taking  place  in  the  urethral  glands,  sub- 
sequent to  urethral  tuberculosis.  The  diagnosis  in  this  case 
lacks  both  clinical  and  pathological  confirmation  and  must  be 
questioned. 

The  urethroscopic  diagnosis  of  tuberculous  lesions  should  offer 
no  difficulty.  In  the  preulcerative  stage  of  minute  tuberculous 
deposits,  the  associated  lesions  should  suggest  the  diagnosis.  In 
the  early  ulcerative  stage,  the  location  of  the  lesion  and  the  lack 
of  pronounced  induration  together  with  the  entire  clinical  picture 
makes  the  differential  diagnosis  from  urethral  chancre  easy. 
In  the  advanced  stage  of  ulceration,  especially  the  diffuse  type, 
the  direction  of  the  extension  from  behind  forward  and  the  asso- 
ciated lesions,  serve  to  obviate  the  possibility  of  confounding  it 
with  urethral  chancroid.  The  age  of  the  patient  combined  with 
the  entire  clinical  and  urethroscopic  picture  serves  to  differen- 
tiate distinctly  between  tubercle  and  epithelioma. 

Herpetic  Eruptions  of  the  Urethra. — The  occurrence  of  herpes 
within  the  urethra,  while  comparatively  rare,  has  been  reported 
by  a  number  of  competent  observers.     The  herpetic  eruption 


URETHROSCOPY   OF    THE   DISEASED   URETHRA  215 

within  the  urethra  has  in  practically  every  instance  been  asso- 
ciated with  a  similar  eruption  on  the  glans  or  prepuce  and  the 
inception  and  subsidence  of  the  two  involvements  were  synchro- 
nous. In  all  of  the  studied  cases  the  eruption  within  the  urethra 
was  confined  to  the  first  inch  and  a  half  of  the  canal. 

Endoscopically,  intraurethral  eruptions  have  practically 
the  same  appearance  as  that  of  herpes  of  the  glans  or  prepuce. 
They  arise  as  small  painful  vesicles,  exhibiting  a  tendency  to 
grouping.  These  vesicles  rapidly  break,  leaving  superficial, 
irregular,  markedly  red  erosions  of  the  mucosa.  There  is  no 
peripheral  infiltration. 

The  extremely  painful  character  of  these  lesions,  their  loca- 
tion, their  bright  red  base  and  their  lack  of  surrounding  infiltra- 
tion serve  to  make  the  diagnosis  clear. 

Chancroid. — Chancroid  of  the  urethra  practically  never  oc- 
curs as  a  purely  intraurethral  lesion,  and  it  is  with  extreme  rarity 
that  the  urethra  is  involved  back  of  the  navicular  fossa.  The 
disease  extends  by  continuity  from  the  meatus. 

As  in  chancre,  the  attendant  infiltration  is  so  great  as  to  make 
the  introduction  of  the  urethroscope  both  difficult  and  painful 
and  with  the  exception  of  those  rare  cases  in  which  there  is  a 
marked  tendency  to  phagedena  or  where  the  chancroidal  in^'olve- 
ment  has  extended  to  the  deeper  parts  of  the  urethra  through 
previous  instrumentation,  urethroscopy  is  distinctly  contrain- 
dicated. 

Through  the  urethroscope,  chancroid  appears  as  a  grayish, 
ragged  ulceration  irregular  in  shape  within  definite  borders. 
There  is  a  well-marked  periphery  of  dark-red  infiltration.  If 
the  lesion  is  very  extensive,  there  appear  irregular  patches  of 
non-ulcerated  mucosa,  dark-red  or  bluish-red.  In  other  words, 
as  far  back  as  the  lesion  extends,  the  ulceration  is  practically 
continuous. 

No  differential  diagnosis  is  required,  though  study  of  the 
case  reported  by  Ricord  of  extensive  chancroidal  ulceration 
extending  into  the  bladder,  has  convinced  some  observers  that 


2l6  CYSTOSCOPY   AND    URETHROSCOPY 

the  case  was  one  of  tuberculosis  rather  than  chancroid.  Such 
a  mistake  is  very  unhkely  to  occur  and  we  consider  a  detailed 
study  of  possibly  confusing  conditions  unnecessary. 

Syphilis  of  the  Urethra. — Syphilis  of  the  urethra  presents 
in  two  forms  of  interest  to  the  urethroscopist,  the  primary 
lesion  and  the  mucous  patch.  The  chancre  is  most  commonly 
observed  on  account  of  the  lack  of  subjective  symptoms  to  which 
the  latter  gives  rise,  though  it  is  exceedingly  probable  that  the 
mucous  patch  is  in  reality  the  more  common  lesion. 

Chancres  involving  the  lips  of  the  meatus  or  situated  just 
within  the  meatus  are  of  no  interest  urethroscopically.  Their 
observation  and  diagnosis  via  the  urethroscope  are  required 
only  when  they  are  located  within  the  navicular  fossa  or  back  of 
this  point.  They  are  rarely  located  posterior  to  the  fossa  though 
the  primary  lesion  has  been  found  as  far  back  as  two  inches  from 
the  meatus  (Keyes). 

The  introduction  of  the  urethroscope  in  urethral  chancre 
is  usually  attended  with  considerable  pain  on  account  of  the 
extreme  stiffness  of  the  urethral  wall  in  the  neighborhood  of  the 
lesion.     There  is  a  marked  tendency  toward  bleeding. 

The  uretliroscopic  appearance  of  the  unmixed  form  of  chancre 
is  fairly  typical.  The  chancrous  erosion  may  be  located  at  any 
point  in  the  urethral  lumen  or  it  may  occupy  the  entire  lumen. 
The  ulcerated  surface  is  raw  and  bleeding  with  quite  a  marked 
periphery  of  deep  red  infiltration.  The  edges  of  the  ulcer  are 
clear  cut.  The  appearance  of  the  mixed  form  is  practically  that 
of  urethral  chancroid.  It  must  not  be  forgotten  that  purely 
chancrous  lesions  of  the  urethra  give  rise  to  a  pronounced 
degree  of  infiltration. 
''  In  the  unmixed  form  of  urethral  chancre,  it  is  possible,  though 
hardly  probable,  that  a  differential  diagnosis  may  be  required 
from  tuberculosis  and  carcinoma.  In  tuberculosis  we  find  the 
lesions  to  be  multiple,  relatively  smaller  and  advancing  from 
the  deeper  portions  of  the  urinary  tract.  While  in  its  early 
stage  of  ulceration,  the  tubercle  may  bear  some  resemblance  to 


URETHROSCOPY    OF    THE   DISEASED    URETHRA  21 7 

chancre,  the  rapid  excavation  of  the  tuberculous  lesion  destroys 
this  possible  ( ?)  source  of  error. 

In  carcinoma  we  find  the  growth  almost  always  arising  back 
of  the  peno-scrotal  junction,  usually  in  the  bulbous  urethra.  The 
hemorrhagic  tendency  is  thoroughly  pronounced — far  more  so 
than  in  chancre.  The  growth  bears  practically  no  resemblance 
to  chancre  and  we  cannot  conceive  of  the  possibility  of  confound- 
ing the  two  lesions. 

The  Mucous  Patch. — While  we  believe  that  the  occurrence 
of  the  mucous  patch  within  the  urethra  is  by  no  means  an  un- 
usual accompaniment  of  syphilis,  the  resultant  urethritis  is 
usually  of  such  a  mild  degree  as  to  rarely  attract  the  attention 
of  the  medical  attendant.  Bassereau  and  Bumstead  have, 
however,  reported  cases  in  which  a  profuse  urethritis  developed 
from  the  presence  of  mucous  patches  within  the  urethra.  In  the 
cases  which  we  have  observed,  the  urethritis  was  mild  and  the 
subjective  symptoms  slight — presenting  practically  the  same 
clinical  characteristics  as  an  old  gleet. 

The  endoscopic  diagnosis  offers  no  difficulties  as  the  lesion 
presents  the  same  clinical  peculiarities  that  characterize  it  on 
other  mucous  membranes.  It  is  irregular.  It  is  superficial 
and  accompanied  by  but  slight  infiltration.  The  ulceration  is 
yellowish  and  the  edges  are  well  defined.  The  lesion  may  be 
single,  though  when  the  disturbance  caused  by  the  presence  of 
mucous  patches  within  the  urethra  is  sufficient  to  call  for  inves- 
tigation, it  is  rare  that  but  one  lesion  is  found.  The  presence  of 
secondaries  elsewhere  should  suggest  the  diagnosis  and,  in  fact, 
there  is  but  one  condition  which  it  in  any  way  resembles — the 
chancroid.  The  fact  that  chancroidal  ulcerations  invariably 
extend  by  continuity  from  the  meatus,  coupled  with  the  greater 
degree  of  infiltration  and  the  tendency  to  great  destruction  of 
tissue  which  accompanies  the  chancroid,  should  make  the  differ- 
ential diagnosis  easy. 

Leukokeratosis  (Psoriasis  Mucosa). — The  occurrence  of 
whitish  plaques  on  the  urethral  mucosa  was  first  pointed  out  by 


2l8  CYSTOSCOPY   AND   URETHROSCOPY 

Kollmann  and  Oberlander  who  applied  to  this  condition  the 
term  ''psoriasis  mucosa" — a  term  which  is,  unfortunately,  too 
broad  in  its  application  to  be  definite.  On  account  of  its  analogy 
to  leukoplakia  lingualis,  to  which  Butlin  has  given  the  patho- 
logically correct  term  of  leukokeratosis,  we  deem  it  advisable  to 
apply  the  term  leukokeratosis  urethralis  to  the  condition  de- 
scribed by  Kollmann  and  Oberlander  under  the  more  vague 
name  of  psoriasis  mucosa. 

The  formation  of  these  plaques  on  the  urethral  mucosa  is 
dependent  upon  local  nutritional  disturbances  resulting  in  great 
epithelial  proliferation.  These  disturbances  are  of  an  extremely 
chronic  character  and  practically  always  arise  on  the  areas  of 
infiltration  of  chronic  urethritis. 

Leukokeratosis  urethralis  may  present  as  a  single  isolated 
plaque  or  as  scattered  patches  distributed  over  a  considerable  area. 
It  is  found  in  patients  over  middle  age  and,  as  in  leukokeratosis 
lingualis,  may  be  considered  a  pre-epitheliomatous  condition, 

Endoscopically  considered,  these  plaques  appear  as  flat 
or  slightly  raised  lusterless  white  patches.  They  exhibit  no 
tendency  to  a  regularity  of  outHne.  In  color,  they  vary  accord- 
ing as  the  epithelial  proliferation  has  advanced,  from  a  grayish- 
white  to  a  dead-white.  They  are  with  difficulty  scraped 
from  their  bases  to  which  they  are  firmly  adherent.  They  give 
rise  to  no  subjective  symptoms  and  are  associated  with  a  gleety 
discharge.  Their  urethroscopic  diagnosis  presents  no  diffi- 
culties, as  their  appearance  is  typical.  They  are  unaccompanied 
by  a  general  psoriasis. 

Urethral  Calculi. — Calculi  of  the  urethra  are  either  primary 
and  originating  in  the  urethra  or  secondary,  having  their  origin 
higher  up  in  the  urinary  tract  or  in  the  prostate.  They  occur 
with  extreme  infrequency  in  women,  Finsterer  being  able  to  find 
but  fourteen  recorded  instances  (Deutsche  Zeitschrift  fiir 
Chirurgie,  Last  index,  XL VI,  1404). 

Primary  calculi  of  the  urethra  are  comparatively  rare.  They 
practically  always    have  their  origin  in  valves  or  diverticula, 


URETHROSCOPY   OF    THE   DISEASED    URETHRA  219 

fistulous  tracts  or  behind  some  point  of  extreme  pathological 
narrowing  of  the  urethra.  The  nucleus  may  be  made  up  of 
inspissated  pus  and  epithelium  or  be  formed  around  a  sym- 
pexion.  We  have  observed  a  case  originating  from  Robin's 
sympexions  and  which  is,  as  far  as  our  investigations  have  been 
pursued,  unique.     For  this  reason  we  report  it  in  detail. 

The  patient,  Mr.  S.,  aged  forty-four  years,  had  on  different 
occasions  passed  small  gelatinous-like  bodies  ovoid  in  shape, 
which  on  minute  examination,  corresponded  to  the  vesicular 
formations  described  by  Robin  under  the  name  of  sympexions. 
He  had  a  resilient  stricture  just  anterior  to  the  bulbar  cul-de-sac 
for  which  I  urged  urethrotomy.  He  was,  however,  compelled 
to  go  East  on  some  matters  of  business  before  operation  and  dur- 
ing a  prolonged  stay,  neglected  treatment.  On  his  return  to 
Kansas  City,  we  passed  a  urethroscope  down  to  the  face  of  the 
stricture  which  had  become  greatly  contracted.  Under  air- 
inflation  it  was  possible  to  observe  just  back  of  the  stricture  and 
lying  within  the  cul-de-sac  of  the  bulb,  a  white  body.  A  ure- 
thral probe  demonstrated  that  this  body  was  a  calculus  and  was 
freely  movable.  The  stricture  was  incised  through  our  operating 
urethroscope  and  the  tube  pushed  down  into  the  cul-de-sac. 
The  calculus  entered  the  lumen  of  the  tube  and  was  removed  by 
means  of  an  applicator  loosely  tipped  with  cotton.  It  was  ovoid 
in  shape  and  undoubtedly  phosphatic.  It  was  crushed  accident- 
ally and  found  to  be  merely  a  shell  containing  a  much  smaller 
dried  nucleus  of  what  had  apparently  been  a  sympexion.  The 
sympexion  had  apparently  passed  into  the  cul-de-sac  of  the 
bulb  and  been  held  in  this  location  by  means  of  the  obstruction 
offered  by  the  stricture.  A  deposit  of  urinary  salts  had  taken 
place  and  the  sympexion  had  gradually  disintegrated  leaving 
the  egg-shell  calculus. 

So-called  primary  calculi  having  for  their  nucleus  some  re- 
tained foreign  body  are  not  true  calculi  but  merely  incrustations. 
The  deposit  of  phosphatic  plaques  on  the  urethral  mucosa  is  an 
anomaly,  but  such  a  case  has  been  reported  by  Chute. 


2  20  CYSTOSCOPY   AND    URETHROSCOPY 

Secondary  calculi  may  present  as  (a)  urethral  calculi,  lying 
entirely  in  the  urethra;  (b)  vesico-urethral,  the  so-called  "pipe" 
stones,  lying  partly  in  the  bladder  and  partly  in  the  urethra; 
(c)  prostato-urethral,  originating  as  prostatic  calculi  and  pro- 
jecting into  the  urethra.  The  first  forms  pass  into  the  urethra 
from  the  upper  urinary  tract  and  are  arrested  at  the  points  of 
physiological  narrowing  or  behind  a  stricture.  The  occurrence  of 
prostato-urethral  calculi,  while  denied  by  some  authorities,  is  con- 
firmed with  certainty  by  the  observations  of  Casper  and  others. 

In  both  the  diagnosis  and  treatment  of  calculi  of  the  urethra, 
the  urethroscope  is  indispensable.  The  urethroscopic  appear- 
ance of  calculi  requires  no  especial  description  as  no  differential 
diagnosis  is  required. 

Cyst  of  the  Prostatic  Utricle. — The  occurrence  of  utricular 
cyst  in  the  adult  is  extremely  rare.  Englisch,  in  seventy 
autopsies  on  new-born  infants,  found  this  condition  five  times 
and  Cabot  (Trans.  Amer.  Assn.  G.-U.  Surgeons,  Twentieth 
Annual  Meet.,  Vol.  I,  p.  loi,  1906)  concludes  from  his  investi- 
gations that  it  is  practically  never  found  in  the  adult. 

A  few  instances  have,  however,  been  reported  in  which  the 
cyst  has  been  observed  urethroscopically.  Klotz's  case  ("  Endo- 
scopic Studies,"  N.  Y.  Med.  Jour.,  Jan.  26,  1895)  appears  to  be 
well  authenticated  by  its  clinical  description  though  the  author 
hesitates  to  report  it  unequivocally  as  a  utricular  cyst. 

In  the  few  reported  cases  observed  through  the  urethroscope 
the  existence  of  the  cyst  has  in  every  instance  been  traceable  to 
the  infiltration  of  chronic  lu-ethritis  occluding  what  was  pre- 
sumably originally  a  prostatic  utricle  of  very  small  dimensions. 

Urethroscopically,  such  a  cyst  has  the  peculiar  bluish-white, 
translucent  appearance  of  similar  cysts  of  Littre's  glands  but 
attains  a  size  proportionately  larger.  Its  diagnosis  is  dependent 
upon  its  location  and  the  existence  of  a  surrounding  zone  of 
infiltration. 

Argyria. — Discoloration  of  the  urethral  mucosa  from  the 
topical  use  of  silver  salts,  usually  the  nitrate,  has  been  occa- 


URETHROSCOPY   OF    THE   DISEASED    URETHRA  221 

sionally  observed.  It  results  from  the  oxidation  of  the  silver 
and  the  resultant  staining  is  black  or  brownish-black.  This 
staining  presents  as  isolated  areas  of  discoloration,  sometimes 
being  limited  to  the  orifices  of  the  glands  and  lacunae.  It  may 
disappear  within  a  short  time  or  remain  indelinitel}-. 

The  endoscopic  picture  is  tj-pical.  The  irregular  areas  of 
black  or  brownish-black  discoloration  exhibit  a  loss  of  luster  and 
the  vascularity  is  obscured.  These  spots  are  painless  and  unac- 
companied by  symptoms. 


CHAPTER  V 
OPERATIVE  URETHROSCOPY 

The  practicability  of  the  use  of  the  urethroscope  for  the 
performance  of  certain  intraurethral  operative  maneuvers  has 
long  been  demonstrated  and  Kollman  and  others  have  devised 
numerous  ingenious  instruments  to  be  used  through  the  urethro- 
scope. To  attempt  to  describe  all  of  these  instruments  and 
their  application  is  unnecessary  as  the  use  of  the  various  instru- 
ments is  suggested  by  the  instruments  themselves.  To  certain 
procedures  to  which  we  have  had  recourse  and  which  have 
appealed  to  us  as  being  especially  valuable,  we  shall  accord 
special  mention.  In  intraurethral  work  we  have  found  air-in- 
flation urethroscopy  to  be  practically  indispensable  and  we 
have  made  use  of  the  Ernest  G.  Mark  Aero-Urethroscope  in 
all  work  of  this  character. 

The  Treatment  of  Cystic  Follicles  and  Suppvirating  Glands 
of  Littre. — The  end  to  be  attained  in  these  conditions  is  the 
thorough  destruction  of  the  infected  follicle  or  gland.  Simple 
drainage  has,  in  our  experience,  been  insufiicient. 

This  obliteration  of  the  infected  sac  may  best  be  secured  by 
opening  up  the  sac  through  the  operating  urethroscope  and  then 
destroying  the  infected  area  by  galvano-  or  acid-cauterization. 

The  procedure  we  have  adopted  is  as  follows :  The  urethro- 
scope is  introduced  and  the  infected  follicle  or  gland  brought 
into  the  urethroscopic  field.  A  solution  of  adrenal  extract,  i  to 
1000,  is  applied  with  a  small  pledget  of  cotton  to  the  area  to 
be  operated  upon.  This  is  allowed  to  remain  a  few  minutes. 
The  cotton  is  then  removed  and  a  4  per  cent,  solution  of 
cocaine,  similarly  applied,  is  kept  in  contact  with  the  infected 
gland  or  follicle  for  about  five  minutes.     The  cotton  is  now 


OPERAXrVE   URETHROSCOPY  223 

removed  and  the  operating  window,  through  which  the  knife  is 
passed  and  attached  to  the  handle,  is  introduced,  care  being 
taken  that  when  the  window  is  firmly  attached  the  blade  of  the 
knife  shall  not  protrude  beyond  the  distal  end  of  the  urethro- 
scopic  tube.  Under  air-inflation  the  point  of  the  knife  is  plunged 
into  the  infected  area  and  a  free  opening  made.  The  blood  and 
purulent  material  are  mopped  up  with  cotton-tipped  applicators 
and  the  cavity  thus  exposed  is  seared  over  with  the  urethral 
cautery. 

The  subsequent  treatment  consists  of  the  injection  twice 
daily  of  a  15  per  cent,  solution  of  argyrol.  On  the  fifth  day 
topical  applications  of  12  per  cent,  silver  nitrate  or  of  a  solu- 
tion containing  equal  parts  of  iodine  and  carbolic  acid  may  be 
made  via  the  urethroscope. 

It  seems  unnecessary  to  state  that  the  above  procedure  is 
applicable  only  in  chronic  infections. 

Stricture. — The  employment  of  certain  maneuvers  via  the 
operating  urethroscope  in  the  treatment  of  stricture  has  already 
been  indicated  in  the  chapter  dealing  with  the  urethroscopy  of 
stricture.  In  the  application  of  the  urethroscope  to  the  opera- 
tive treatment  of  stricture,  there  is  no  intent  to  supplant  other 
operative  measures  of  known  value.  The  field  of  urethroscopy 
in  urethral  stricture  is,  of  necessity,  limited  and  we  shall  consider 
the  operating  urethroscope  rather  in  the  light  of  a  valuable 
adjunct. 

In  so-called  impermeable  stricture,  where  it  is  found  ex- 
ceedingly difficult  or  impossible  to  introduce  even  a  filiform 
bougie  we  have  found  the  following  procedure  of  great  service. 

The  urethroscope  is  introduced  down  to  the  face  of  the 
obstruction.  Often  this  is  impossible  on  account  of  coexisting 
strictures  of  lesser  degree  anterior  to  the  point  of  apparent 
impermeability.  When  the  instrument  is  introduced  as  far  as 
possible,  the  observation  window  is  attached  and  air-inflation 
employed.  Even  though  the  urethroscope  may  not  have  been 
passed  to  the  main  point  of  obstruction,  the  ballooning  of  the 


2  24  CYSTOSCOPY   AND   URETHROSCOPY 

urethra  will  bring  this  point  into  view.  If  false  passages  coexist, 
then  differentiation  from  the  contracted  urethral  lumen  is 
readily  made  {vide  page  195).  If  there  is  accompanying  bleeding 
the  application  of  adrenal  extract,  i  to  1000,  is  of  service,  both 
in  stopping  the  bleeding  and  in  lessening  the  congestion. 

The  observation  window  is  replaced  by  the  operating  window 
and  a  whalebone  filiform  passed  through  it.  The  urethra  is 
inflated  and  with  the  narrowed  lumen  in  view  the  bougie  is 
passed  into  and  through  it.  With  the  filiform  in  place,  further 
procedures  may  be  left  to  the  discretion  of  the  surgeon. 

In  the  cases  in  which  we  have  employed  this  procedure,  we 
have  found  it  easy  of  accomplishment  and  thoroughly  practi- 
cable. In  most  of  these  cases  there  have  been  persistent  un- 
successful attempts  to  pass  filiforms  and  in  the  majority  of  such 
cases  there  have  been  accompanying  false  passages. 

In  the  time-honored  performance  of  internal  urethrotomy, 
the  procedure  has  been  stereotyped  and  especial  insistence  has 
been  made  that  the  incision  be  made  in  the  median  line  of  the 
roof  of  the  canal.  This  has  been  considered  an  absolute  es- 
sential of  the  operation. 

In  the  urethroscopic  study  of  stricture  it  will  be  found  that 
the  obstruction  in  the  majority  of  instances  does  not  present  at 
the  upper  middle  portion  of  the  urethral  lumen.  It  will  be  found 
usually  to  one  side  of  the  median  line,  occasionally  on  the  floor. 
Under  such  circumstances,  and  they  are  the  usual  ones,  severing 
the  relatively  normal  mucosa  in  the  upper  median  line  and 
leaving  the  infiltrated  portion  untouched,  does  not  appeal  to  us 
as  a  logical  procedure. 

The  application  of  the  urethroscope  to  the  performance  of 
accurate  internal  urethrotomy  is  in  our  judgment  almost 
indispensable.  We  employ  it  as  follows:  (i)  To  locate  ac- 
curately the  relation  of  the  infiltration  to  the  urethral  circumfer- 
ence. (2)  If  the  stricture  is  of  a  filiform  caliber,  it  is  quite 
possible  by  means  of  the  intraurethral  knives  used  via  the 
operating  window,  to  so  incise  the  infiltration  that  the  passage 


OPEEATIVE   URETHROSCOPY  225 

and  further  use  of  the  urethrotome  becomes  possible,  the  best 
line  of  cleavage  having  been  ascertained  by  means  of  the  urethro- 
scope. (3)  In  fairly  extensive  cicatricial  formations,  it  has  been 
found  impracticable  to  perform  internal  urethrotomy  \da  the 
'urethroscope  on  account  of  the  essential  feature  of  dilatation 
which  is  afforded  by  the  ordinary  urethrotome.  In  such  cases 
the  urethroscope  is  used  merely  for  the  purpose  of  accurately 
locating  the  relative  position  of  the  infiltrated  area.  The  ure- 
throtome is  then  introduced  and  the  incision  made  according 
to  the  information  gained,  absolutely  no  attention  being  paid 
to  the  old  rule  of  cutting  directly  in  the  median  line  of  the  roof. 

Papillomata. — Various  procedures  for  the  removal  of  papil- 
lomata  situated  in  the  urethra  have  been  de\dsed.  Several  years 
ago  Oberlander  suggested  the  following  method  which  was  fairly 
successful  and  met  with  general  approval. 

Oberlander's  Method. — Pass  the  urethroscope  beyond  the 
point  of  involvement.  Pass  through  the  tube  two  cotton- 
bearing  applicators.  Remove  the  tube  leaving  the  applicators 
in  situ.  Extend  the  canal  by  pulling  on  the  penis  and  by 
alternately  pushing  and  pulling  on  the  applicators,  lacerate  the 
growths. 

The  preceding  operation  is  crude  and  must  be  considered 
obsolete. 

Schwartz  devised  a  method  for  the  removal  of  various 
urethral  growths  which  is  fairly  practicable  and  efficacious. 

Schwartz's  Method. — The  instrument  is  made  up  of  an 
ordinary  urethroscopic  tube  having  near  its  distal  end  an  open 
window  placed  laterally  and  a  second  tube  made  to  closely  fit  the 
lumen  of  the  first.  The  edges  of  the  distal  opening  in  the 
second  tube  are  sharp. 

The  first  tube  is  introduced  with  obturator  in  place.  The 
obturator  is  withdrawn  and  by  manipulation  the  growth  is  made 
to  project  into  the  lumen  of  the  tube  through  the  laterally  placed 
window.  The  second  tube  is  now  introduced,  the  cutting  edges 
of  which  shave  off  the  projecting  growth.  This  instrument 
15 


226  CYSTOSCOPY   AND   URETHROSCOPY 

with  various  modifications  has  been  presented  quite  frequently, 
the  last  presentation  being  that  of  Young,  of  Baltimore,  before 
the  American  Urological  Association  in  1909  (Trans.  Amer. 
Urolog.  Assn.,  1909). 

Both  the  hot  and  cold  snare  have  been  suggested  and  utilized 
by  various  writers,  much  being  claimed  for  the  former  method. 

Authors'  Method. — The  urethra  is  anesthetized  by  the  use  of 
alypin  or  cocaine.  Adrenalin  is  applied  freely  to  the  growths  by 
means  of  cotton  swabs  passed  through  the  urethroscope  and  left 
in  situ  for  a  few  moments. 

The  urethroscope  is  now  passed  beyond  the  point  of  further- 
most involvement,  the  secretions  mopped  up  and  the  observation 
window  attached.  The  urethra  is  now  inflated  with  air  and 
slowly  withdrawn.  When  papillomatous  masses  present  in  the 
field,  the  urethroscope  is  inclined  at  a  slight  angle  toward  the 
growth,  and  the  urethra  being  inflated  beyond  the  growth,  the 
urethroscope  is  pushed  quickly  against  the  tumor  at  its  base,  the 
sharp  edges  of  the  distal  extremity  of  the  tube  shaving  the 
growth  from  the  urethral  wall. 

This  procedure  is  accompanied  by  practically  no  bleeding. 
The  instrument  is  still  further  withdrawn  and  as  other  masses 
come  into  view,  the  same  procedure  is  made  use  of. 

After  all  growths  have  been  removed,  the  urethra  is  stripped 
to  empty  it  of  the  detached  papillomatous  masses  and  adrenalin 
is  instilled  into  the  canal.  In  a  few  minutes  the  urethroscope  is 
reintroduced  and  the  points  of  former  attachment  of  the  papil- 
lomata  are  slightly  touched  with  a  fine  galvano-cautery  point. 
Subsequent  treatment  is  made  at  the  discretion  of  the  operator. 

Other  Tumors. — In  the  removal  of  other  growths  of  the 
urethra,  the  urethroscope  plays  but  little  part  unless  the  growth 
be  pedunculated  and  non-malignant.  In  tumors  of  this  char- 
acter, the  galvano-cautery  snare  may  be  used  with  success. 

Enlarged  Turgescent  Verumontanum. — Where  this  condition 
is  persistent  and  resists  the  topical  applications  of  silver  salts, 
the  partial  removal  of  the  enlarged  veru  is  indicated.     For  this 


OPERATR'E  URETHROSCOPY  227 

purpose  the  galvano-cautery  knife  or  snare  is  of  much  service. 
Hawkins,  of  Pittsburg,  has  made  use  of  the  same  procedure  for 
the  removal  of  the  veru  as  that  advocated  by  the  authors  for  the 
removal  of  urethral  papillomata,  i.e.,  shaving  off  the  growth  with 
the  urethroscopic  tube. 

Vesiculitis  and  Strictures  of  the  Ejaculatory  Duct. — In 
1904  one  of  us  (Mark)  presented  to  the  American  Urological 
Association  the  fallaciousness  of  the  view  formerly  held  as 
as  to  the  extremely  small  size  of  the  ejaculatory  duct.  It  was 
found  possible  to  pass  into  the  ejaculatory  ducts  of  prostates 
remo^'ed  from  the  cadaver  probes  of  ordinary  size.  Reasoning 
from  this  knowledge  the  possibility  of  medication  to  the  vesicles 
and  ampullae  of  the  vasa  by  means  of  injections  through  long 
canulae  passed  via  the  urethroscope  was  suggested  and  has  been 
carried  out  in  a  number  of  instances.  We  do  not,  however, 
consider  the  procedure  to  be  practicable  in  most  instances  on 
account  of  the  distortion  of  the  structures  in  the  prosta- 
tic urethra  by  accompanying  disease  of  this  portion  of  the 
urethra. 

In  stricture  of  the  ejaculatory  duct  it  is  advisable  to  attempt 
dilatation  of  the  duct  by  means  of  whalebone  filiforms  passed  via 
the  urethroscope. 

The  passage  of  small  probes  and  canulae  into  the  orifices  of 
the  ducts  is  sometimes  surprisingly  easy  of  accomplishment  and 
in  all  cases  of  chronic  vesiculitis,  is  worthy  of  a  trial. 

Valves  and  Diverticula. — Vah^ular  folds  and  diverticula  whose 
openings  are  toward  the  meatus  are  readily  obliterated  by 
splitting  up  the  folds  via  the  urethroscopic  tube  with  urethral 
scissors  or  a  curved  knife.  The  small  tags  left  by  this  splitting 
quickly  contract  and  practically  disappear. 

Operative  work  on  those  valves  whose  openings  are  toward 
the  bladder  is  more  difficult.  In  the  one  case  of  this  character 
observed  by  us  we  made  use  of  the  following  procedure  which 
seems  to  us  to  be  readily  applicable  and  indicated  in  all  cases 
of  this  character. 


2  28  CYSTOSCOPY    AND    URETHROSCOPY 

Author's  Method. — The  author's  air-inflation  urethroscope 
was  introduced  to  a  point  just  beyond  the  valve  and  withdrawn 
until  the  edge  of  the  valvular  fold  came  into  view.  The  opera- 
tive window  with  the  curved  knife  attached  was  now  afi&xed  to 
the  urethroscope  and  with  the  stop-cock  to  the  urethroscope 
turned  off,  the  dilating  bulbs  were  inflated.  The  stop-cock  w^as 
now  opened  and  the  urethra  inflated  with  a  sudden  inrush 
of  air.  The  air  striking  the  interference  opposed  by  the  com- 
pressor at  the  anterior  layer  of  the  triangular  ligament  was 
thrown  back,  lifting  up  the  valvular  fold  into  the  urethral 
lumen.  With  steady  pressure  of  air  the  fold  was  kept  in  its 
extended  position  and  the  knife  passed  through  the  center  of  its 
apex  and  the  fold  completely  split,  thus  obliterating  it.  Com- 
plete and  immediate  relief  from  symptoms  followed. 

Foreign  Bodies. — The  long  list  of  foreign  bodies  found  in  the 
urethra  precludes  individual  mention.  It  suffices  to  say  that 
the  removal  of  the  majority  of  these  is  rendered  easy  by  the  use 
of  the  urethroscope. 

In  work  of  this  character  it  is  best  to  use  a  tube  of  fairly  large 
caliber.     Air-inflation  is  distinctly  advantageous,  if  not  essential. 

The  endoscopic  tube  is  introduced  down  to  the  foreign  body 
which  can  usually  be  palpated  through  the  urethra.  If  the 
foreign  body  is  in  the  penile  urethra  it  is  well  to  compress  the 
urethra  proximally  to  the  body  so  as  to  prevent  its  being  pushed 
further  into  the  urethra. 

The  usual  urethroscopic  technique  is  observed  and  the 
foreign  body  having  been  once  brought  into  view,  its  removal  is 
dependent  upon  the  ingenuity  of  the  operator. 

In  the  removal  of  sharp  substances  such  as  spiculated  stones, 
pins,  pieces  of  glass,  etc.,  great  care  must  be  taken  to  prevent 
undue  laceration  of  the  urethral  mucosa.  The  ordinary  types 
of  alligator- jawed  urethral  forceps  are  the  only  accessories 
needed. 

Warning. — Within  the  past  three  years  we  have  observed  cer- 
tain phenomena  occuring  in  operative  work  under  air-inflation 


OPERATIVE  URETHROSCOPY  229 

which  have  led  us  to  believe  that  there  are  certain  dangers 
against  which  a  warning  must  be  issued.  In  the  Journal  of 
the  A.  M.  A.,  February  ii,  191 1,  we  reported  a  case  of  air 
embolus  which  occurred  during  operation  under  air-inflation 
urethroscopy.  While  this  case  did  not  come  to  a  fatal  issue, 
the  possibility  of  such  an  issue  must  not  be  denied.  We  have 
observed  cases  in  which  localized  emphysema  occurred  during 
intraurethral  operative  work  and  we  believe  that  all  of  these 
cases  have  been  caused  by  an  undue  amount  of  air-inflation. 
Therefore,  in  all  cutting  operations  in  the  urethra  under  air- 
inflation  the  bulbs  should  be  released  at  the  moment  of  the 
incision  so  that  air  cannot  be  forced  into  the  tissues  thus  opened 
up.  We  believe  that  if  this  rule  is  followed  no  untoward 
symptoms  will  arise  in  work  of  this  character. 


INDEX 


Adenoma  of  the  bladder,  109 

Accessories,  cystoscopic,  17 

Acute  cystitis,  95 

Afterword  on  tumors  and  changes  in 

bladder,  121 
Air-inflation  of  bladder  by  Rutenberg,  6 

cystoscopy,  technique,  28 
heated  air  preferred  in,  30 
position  of  patient  for,  29 
Albarran's  lever  device,  10 
Anatomy  of  bladder,  i 
Anatomy  of  male  urethra,  155 

Cowper's  glands,  160 

Littre's  glands,  159 

prostatic  follicles,  160 

the  trigone,  2 
Analgesia  required  in  cystoscopy,  23 

method  of  securing,  23 
Appearance  of  normal  bladder,  31 

of  normal  ureteral  orifice,  33 
Armamentarium,  cystoscopic,  15 


Bladder,  tuberculosis  of,  109 
tumors  of,  loi 
adenoma,  109 
carcinoma,  105 

contraindication  to  cystoscopy 

in,  102 
sessile  growth,  105 
villous-covered  growth,  105 
divisions  of,  loi 
fibroma,  109 
myoma,  109 
myxoma,  109 
papilloma,  103 
color  of,  104 
treatment  of,  104 
types  of,  103 
villi  in,  104 
sarcoma,  105 
ulcer  of,  simple,  115 
tuberculous,  1 1 1 
Box  phantom,  Valentine's,  35 
Bransford  Lewis'  first  cystoscope,   10 
fulguration  apparatus,  139 


B 


Beer's  treatment  of  vesical  tumors, 
Bierhoflf's  modification  of   Nitze's 

toscope,  1 1 
Bilharzia  disease,  107 
Bladder,  anatomy  of,  i 
bullous  edema  of,  117 
coloring  of  normal,  31 
congestion  of,  94 
cysts  of,  dermoid,  107 
echinococcus,  108 
follicular,  107 
diverticula  of,  117 
leukoplakia  of,  118 
lymphoid  tubercle  of,  112 
trabeculation  of,  117 
tabetic,  118 


138       Calculi  of  bladder,  97 
cys-  encysted,  98 

of  ureter,  90,  119,  147 

removal  of,  147 
of  urethra,  218 
Catheters  for  ureteral  catheterization,  18 
selection  of,  43 
sterilization  and  care  of,  34 
Carcinoma  of  bladder,  105 

of  urethra,  207 
Catheterization  of  bladder  before  using 
cystoscope,  29 
of  male  ureter,  9 
ureteral,  in  America,  9 
ureteral,  37 

choice  of  methods  in,  41 
231 


232 


INDEX 


Catheterization,  ureteral,  dangers  of,  63 

diagnosis  by,  39 

difficulties  in,  60 

direct  method,  preference  for,  42 
technique  of,  45 

history  of,  37 

indirect  method,  technique  of,  52 

Pawlik-Kelly  method,  58 
technique  of,  45 

purposes  of,  39 

treatment  by,  40 

under  forced  air-inflation,  57 

X-ray  work  in,  45 
Cauterization  through  cystoscope,  135 
Chancroid  of  urethra,  215 
Chromocystoscopy,  63 
Classification  of  bladder  tumors,  100 
Congenital    malformations    of    kidney 

and  ureter,  85 
Congestion  of  bladder,  94 
Cowper's  glands,  160 
Cryoscopy,  66 
Cystic  kidney,  82 

distention  of  lower  end  of  ureter,  120 
follicles,  221 
Cystitis,  acute,  95 

subacute  and  chronic,  95 
Cystoscopes,  historical  review,  4 

Bierhoff's  modification  of  Nitze's, 
II 

Boisseau  du  Rocher's,  8 

Bozzini's,  4 

Bransford  Lewis',  10,  11,  130 

Brenner's,  9 

Brown-Buerger's,  14 

composite,  first,  8 

Leiter's,  7 

Nitze's,  6 

requirements  in,  16 

Tilden-Brown's,  10,  11 
Operative,  125 

air-inflation  instruments,  127 

Bransford  Lewis',  130 

Casper's,  128 

Cathelin's,  125 

Luys',  125 

Nitze's,  127 
Cystoscopic  accessories,  17 
armamentarium,  15 


Cystoscopy,  i 

air-inflation  in,  28 
technique  of,  28 
analgesia  in,  23 
divisions  of  bladder  for,  2 
fallacies  in  findings,  33 
free  irrigation  in,  16 
indications  for,  22 
interpretation  of  picture,  34 
of  normal  bladder,  31 
of  pathologic  bladder,  94 
of  stone  in  bladder,  97 

in  ureter,  119 
of  vesical  new  growths,  loi 
of  tuberculosis  of  bladder,  109 
of  tumors  of  bladder,  100 
Pawlik-Kelly's  method  of,  30 
preparation  of  patient  for,  22 
Valentine's  phantom  in,  35 

Operative,  122 

cauterization  in,  135 
cystoscopes  used  in,  125 
fulguration  by,  137 
in  ureteral  calculi,  147 
in  ureteral  stricture,  146 
purposes  of,  124 
Cysts,  dermoid,  107 

echinococcus,  108 

follicular,  107 

of  Littre's  glands,  189 

of  prostatic  utricle,  220 

of  urethra,  190 


D 


Dangers  of  ureteral  catheterization,  63 
Dermoid  cysts  of  bladder,  107 
Desormeaux's  endoscope,  5 
Diagnosis  of  adenoma,  109 
Bilharzia  disease,  107 
bullous  edema,  117 
carcinoma  of  bladder,  105 

urethra,  207 
chancroid  of  urethra,  215 
congestion  of  bladder,  94 
congenital  malformations  of  kidney 

and  ureter,  85 
cystic  distention  of  lower  end  of  the 
ureter,  120 


INDEX 


233 


Diagnosis  of  cystic  kidney,  82 
cystitis,  95 
cysts  of  bladder,  107 

Littre's  glands,  189 

prostatic  utricle,  220 

urethra,  190 
dilatation,  ureteral,  205 
diverticula  of  bladder,  117 

acquired,  117 

congenital,  117 

urethra,  199 
acquired,  199 
congenital,  199 
eversion  of  ureteral  orifice,  119 
fibroma  of  bladder,  109 

urethra,  203 
fibroma-myoma  of  bladder,  109 

urethra,  202 
fibro-myxoma  of  bladder,  109 

urethra,  202 
fibro-sarcoma  of  urethra,  211 
functionating  capacity  of  kidney, 

63 

herpes  of  urethra,  21 

hydronephrosis,  40 

inflammatory    dilatation    of    renal 

pelvis,  77 
lacunae  of  Morgagni,  diseased,  189 
leukoplakia  of  bladder,  118 

urethra,  217 
lymphoid  tubercle,  112 
papilloma  of  bladder,  103 

urethra,  200 
polypi  of  urethra,  202 
pyelitis,  40,  77 
pyonephrosis,  40 
sarcoma  of  bladder,  106 

urethra,  210 
solitary  kidney,  90 
stricture  of  ureter,  40,  44- 

urethra,  194 
stone  in  bladder,  97 

ureter,  90 

urethra,  218 
syphilis  of  urethra,  216 
trabeculation  of  bladder,  1 1 8 

tabetic,  117 
tuberculosis  of  bladder,  109 

kidney,  85,  112 


Diagnosis  of  tuberculosis  of  urethra,  212 

ulcer,  simple,  of  bladder,  115 
tubercular,  11 1 

valves  of  urethra,  197 

varices  of  bladder,  108 
urethra,  205 
Ducts,  ejaculatory,  183 

orifices  of,  183 

size  of,  183 

stricture  of,  227 


E 


Echinococcus  disease,  108 
Edema  buUosum,  117 
Ejaculatory  ducts,  183 

orifices  of,  183 

size  of,  183 

stricture  of,  183 
Endoscope,  Desormeaux's,  5 

Fisher's,  5 

Grunfeld's,  5 

Haken's  modification  of,  5 
Endoscopy,  historical  review,  4 
Eversion  of  ureteral  orifice,  119 
Examination  of  bladder,  27 
Excretion  of  phenolsulphonephthalein, 
69 

in  normal  cases,  69 

(see  phenolsulphonephthalein  test) 
67 
Extrarenal    shadows,    identification  of. 


Fallacies  in  cystoscopic  findings,  33 
Fibroma  of  bladder,  109 

urethra,  203 
Fibro-myoma  of  bladder,  109 

urethra,  203 
Fibro-myxoma  of  bladder,  109 

urethra,  203 
Fisher's  endoscope,  5 
Follicular  cysts,  107 
Follicles,  prostatic,  160 
Foreign  bodies  in  urethra,  228 

removal  of,  228 
Free  irrigation  through  cystoscope,  16 


234 


INDEX 


Fulguration,  apparatus,  138 

Beer's  report,  1909-1911,  140 
Beer's  report,  1912,  142 
cauterization  by  means  of,  137 
Keyes'  report,  1913,  143 
technique,  139 

Functionation  of  kidney,  63 


Glands,  Cowper's,  160 
Littre's,  159 

appearance  of,  180 

H 

Haken's  modification  of  endoscope,  5 
Hemoglobinometer,  Hellige,  69 
Hemorrhage  in  bladder  tumors,  loi 

control  of,  loi 

of  urethra,  208 
Herpetic  eruptions  of  urethra,  214 
Hydronephrosis,  75 

diagnosis,  77 


Incandescent  lamp,  first  use  of,  7 
Identification  of  extrarenal  shadows,  84 

intrarenal  shadows,  84 
Inflammatory  dilatation  of  the  kidney 

pelvis,  77 
Inflation  of  bladder  by  air,  28 

Pawlik-Kelly  method,  30 

urethra,  164 
Instruments,  care  and  sterilization  of, 

18,  168 
Interpretation  of  cystoscopic  picture,  34 
Irrigation  through  cystoscope,  17 


Lacunae  of  Morgagni,  180 

appearance  of,  180 
Lamp,  first  use  of  incandescent,  7 

general  use  of,  7 

low  amperage  (cold),  10 
Leukokeratosis  of  urethra,  217 
Leukoplakia  of  bladder,  118 
Litholapaxy,  cystoscopic,  128 
Littre's  glands,  159 

appearance  of,  180 
Localization  of  renal  shadows,  82 

stones  in  renal  pelvis,  83 
Luster  of  normal  bladder,  32 

urethra,  180 
Lymphoid  tubercle,  1 1 2 

appearance  of,  115 

Kretschmer's  studies  of,  113 

location,  115 

M 

Male  urethra  anatomy  of,  156 
Cowper's  glands  in,  160 
Littre's  glands  in,  159 
natural  constrictions  in,  156 
prostatic  follicles,  160 

Male  ureter,  catheterization  of,  9 

congenital  malformations  of,  85 

Malignant  sessile  growth  of  bladder,  105 
villous  covered,  105 

Mark's  aero-urethroscope,  165 

Meatoscopy,  ureteric,  119 

Methods    of    ureteral    catheterization, 
choice  of,  41 

Mode  of  use  of  Lewis'  cystoscope,  133 

Morgagni,  lacunae  of,  180 

Myxoma  of  bladder,  109 


Janet's  syringe,  18 

use  of,  in  cystoscopy,  18 

K 

Kidney,  cystic,  82 
functionation,  63 

tests  for,  63,  64,  66,  67  and  70 


N 


New  growths,  cystoscopy  of,  loi 

progress  of  (Fenwick),  loi 
Normal  bladder,  examination  of,  27 

appearance  of,  31 

coloring  of,  31 

luster  of,  32 

vascularity  of,  31 


INDEX 


235 


Normal  pelvis  of  kidney,  75 

pyelography  of,  75 
Normal  urethra,  170 

urethroscopy  of,  170 

O 

Operative  cystoscopy,  122 

air-inflation  cystoscopes,  125 
Bransford  Lewis'  instrument  in, 

125 

accessories  for,  125 

technique  of,  130 
cauterization  by,  135 
fulguration  by,  137 

apparatus,  138 
Kelly's  method,  125 
Litholapaxy  in,  128 
Luys'  instrument  in,  125 
purposes  of,  124 

technique  of,  in  Nitze's  instru- 
ment, 127 
urethroscopy,  222 

possibilities  of  accident  in,  228 
removal  of  foreign  bodies  by,  228 

of  verumontanum,  226 
treatment  of  diverticula,  226 

stricture,  223 

strictures   of    the    ejaculator>' 
ducts,  227 

valves,  227 

author's  method,  228 

vesiculitis,  227 


Papilloma  of  bladder,  103 

urethra,  200 
Pawlik-Kelly    method    of    inflation    of 

bladder,  30 
Pedersen's    divisions    of    bladder    for 

cystoscopy,  2 
Pelvis,   renal,  inflammatory  dilatation 

of,  77 
normal,  75 
Phenolsulphonephthalein  test,  67 
Phloridzin  test,  64 

Platinum  loop  period  of  endoscopy,  5 
Polypi  of  urethra,  202 


Posterior  urethroscopy,  181 
Preparation  of  patient  for  cystoscopy, 
22 

urethroscopy,  172 
Preston's  cold  lamp  urethroscope,  164 
Prolapse  of  ureteral  orifice,  119 
Prostatic  utricle,  161 

cysts  of,  220 
Psoriasis  mucosa,  217 
Pyelitis,  indications  of,  77 

treatment   through  ureteral  cathe- 
terization, 65 
Pyelography,  71 

R 

Radiography,  contraindications  to,  92 
failure  of,  74 

identification  of  extrarenal  shadows 
by,  84 
intrarenal  shadows  by,  84 
in     congenital     malformations     of 
kidney  and  ureter,  85 
cystic  kidney,  82 
deformity  due  to  renal  tumors, 

79 

differentiation  of  tumors  of  the 

upper  abdomen,  81 
hydronephrosis,  75 
inflammatory   pelvic   dilatation, 

71 
localization  of  renal  shadows,  82 
media  used  in,  71 

amount  necessary,  72 
of  normal  renal  pelvis,  75 
renal  tuberculosis,  85 
solitary  kidney,  90 
technique  of,  71 
ureteral  dilatation,  90 
used  in  kidney  pelvis  and  ureter,  71 
Requirements  in  cystoscopes,  16 
Rheostats,  135 

Bransford  Lewis',  135 
Rutenberg's  female  vesical  speculum,  6 


Sarcoma  of  bladder,  106 

urethra,  210 
Schlagintweit's  cystoscope,  1 1 
Segalas'  urethro-cystic  speculum,  4 


236 


INDEX 


Segregators,  arguments  against  use  of, 

39 

varieties  of,  39 
Sessile  growths  in  bladder,  105 
Simple  ulcer  of  bladder,  115 
Sinus  pocularis,  183 
Solitary  kidney,  90 
Sterilization  of  instruments,  20,  168 
Stomatoscope  of  Bruck,  5 
Stone  in  bladder,  97 
appearance  of,  97 
diagnosis  of,  97 
in  ureter,  147 

cystoscopic  method  of  removal, 
149 
in  urethra,  218 

removal  by  urethroscope,  219 
Stricture,  ureteral,  144 
treatment  of,  144 
urethral,  192 

air-inflation  urethroscopy  in,  195 
appearance  of,  194 
classification  of,  194 
diagnosis  of,  194 
false  passages  in,  195 
pathology  of,  194 
relative  location  of,  197 
treatment  through  urethroscope, 
223 
Suppurative  glands  of  urethra,  190 

treatment  of,  222 
Syphilis  of  urethra,  216 
Syringe,  Janet's,  18 


Tabes,  diagnosis  of  cystoscope,  118 
Technique  of  cystoscopy,  22 

fulguration,  140 

functional  kidney  tests,  63 

operative  cystoscopy,  122 
urethroscopy,  222 

uretero-pyelography,  71 

urethroscopy,  171 
Tests  for  functional  capacity  of  kidney, 

63 

by  chromocystoscopy,  63 
hemo-cryoscopy,  66 
indigo-carmine,  63 
iodide  of  potassium,  64 


Tests  by  methylene-blue,  63 

phenolsulphonephthalein,  67 
phloridzin,  64 
urino-cryoscopy,  66 
Three-ureter  cases,  10 
Tilden  Brown's  cystoscope,  118 
Trabeculation,  true,  118 

apparent,  34,  118 

tabetic,  118 
Trigone,  anatomy  of,  2 

variations  in,  32 
Tuberculosis  of  bladder,  109 

kidney,  85 

urethra,  212 
Tumors  of  bladder,  100 

classification  of,  100 

contraindications  to  cystoscopy  in, 
102 

control  of  hemorrhage  in,  loi 

cystoscopy  of,  100 
care  in,  102 

Keyes'  criteria  for  fulguration  in,  1 44 

location  of,  103 

progress  of,  loi 

urethra,  199 

U 

Ulcer  of  bladder,  simple,  115 
tuberculous,  11 1 
traumatic,  116 
Ureters,  supernumerary,  86 
Ureteral  calculi,  147 
catheterization,  37 

by  direct  method,  45 

by  indirect  method,  52 

catheters  used  in,  18,  43 
care  and  sterilization  of,  21 

choice  of  method,  41 

cystoscopes  used  in,  4 

dangers  of,  63 

difficulties  in,  60 

Pawlik-Kelly  method  in,  58 

purposes  of,  39 

under  forced  air-inflation,  57 
dilatation,  90 
orifices,  eversion  or  prolapse  of,  119 

location  of,  33 

variation  of  appearance  in,  33 
stenosis  or  obstruction,  146 


INDEX 


237 


Ureteral  stricture,  144 
Ureteric  meatoscopy,  119 
Uretero-pyelography,  7 1 
Urethra,  anatomy  of  normal,  155 
argyria  of,  220 
calculi  of,  218 
chancroid  of,  215 
cyst  of  prostatic  utricle,  220 
diverticula  of,  199 
elasticity  of,  178 
herpes  of,  214 
histology,  158 
leukokeratosis  of,  217 
luster  of,  180 

pathologic  conditions  of,  186 
chronic  urethritis,  186 

appearance  of  glands  in,  189 
changes  in  elasticity  in,  186 

in  luster  in,  188 
glandular  form  of,  189 
modifications    in    vascularity 

in,  188 
Oberlander's  classification  of, 

186 
of  membranous  urethra,  192 
posterior  urethra,  191 
sphincters  of,  158 
stricture  of,  192 
syphilis  of,  216 
tuberculosis  of,  212 
tumors  of,  199 
carcinoma,  207 
fibromata,  203 
fibro-myomata,  203 
fibro-myxomata,  203 
papillomata,  200 
polypi,  202 
sarcomata,  210 
vascular  polypi,  203 
valves  in,  205 
varices  of,  205 
vascularity  of,  179 
Urethroscope,  development  of  the,  162 
air- inflation,  164 
Antal's,  164 
Buerger's,  181 

care  and  sterilization  of,  168 
Goldschmidt's,  166 
Kollmann's  operative,  165 


Urethroscope,  Mark's,  165 
McCarthy's,  181 
methods  of  illumination  of,  164 
Oberlander's,  181 
requirements  of,  167 
types  of,  164 
Valentine's,  164 
Walker's,  166 
Urethroscopy,  analgesia  in,  170 
applicators  used  in,  175 
fallacy  in  use  of  small  tube,  170 
indications  for,  1 70 
lubricants  used  in,  172 
of  male  urethra,  170 

female  urethra,  184 
points  observed  in,  177 
position  of  patient  for,  170 
posterior,  181 

straight  tubes  in,  181 
technique  of,  182 
operative,  222 

in  cystic  follicles  and,  222 
enlarged  verumontanum,  226 
foreign  bodies,  228 
papillomata,  225 

Mark's  method  of  removal, 

226 
Oberlander's  method,  225 
Schwartz'  method,  225 
stricture,  223 
suppurating  glands  of  Littre, 

222 
tumors,  226 

valves  and  diverticula,  227 
Mark's  method,  228 
vesiculitis  and  strictures  of 
ejaculatory  duct,  227 
water-inflation  in,  167 
practical  value  of,  167 
Urethro-cystic  speculum,  4 


Valentine's  box  phantom,  35 
Valves,  urethral,  197 

urethroscopic  treatment  of,  227 
Mark's  method,  228 
Varices  of  bladder,  108 

cystoscopic  appearance  of,  108 


238 


INDEX 


Varices  of  urethra,  205 
Klotz'  case,  206 
Young's  case,  206 
Vascularity  of  normal  bladder,  227 
Vascular  polypi  of  urethra,  227 
Vesiculitis,  227 
Verumontanum,  160,  181 

removal  of  enlarged,  226 
variations  in,  183 


W 
Walker's  urethroscope,  166 
Water  distention  of  bladder  for  cysto- 
scopy, 5 
advantages  of,  28 
cystoscopes,  5,  6 
Janet's  syringe  in,  18 
Politzer's  bag  in,  18 
urethroscopes,  166 


Date  Due 

"~" 

L.  B.  Cat  ] 

fJo.  1137 

